Managing Acute Care for People across the Health Care System - Is more capacity the answer? Dr Ian Sturgess Partner, NHS Interim Management and Support National Clinical Lead for Urgent and Emergency Care, Intensive Support Team
What are we trying to achieve? Getting patients better faster and safer through better integration and alignment. Pursuing Perfection Safety Ideal Care No avoidable deaths No harm No unnecessary pain No waste No delays No feelings of helplessness No inequality Flow Reliability
"Hospital beds by country", OECD. Retrieved fromhttp://www.nationmaster.com/graph/hea_hos_bed-health-hospital-beds
Emergency Care Improvement Understanding demand : capacity : activity : queue Setting Intent Data vs Intelligence Leadership Executive and Clinical Governance Bottlenecks in the System Silos vs Integration Rework and unnecessary steps Sharing and Trust Does the system say YES or NO
Defining demand, capacity activity and queue Demand on the services is all the requests or referrals into the service from all sources Capacity is all of the resources required to do the work and includes staff and equipment Activity is the work done, it is the throughput of the system Backlog is the demand which has not been dealt with the queue or waiting list
Demand and capacity definitions: Demand = All requests for a service = what we should do Waiting list, queue = what we should have done Capacity = what we could do Activity = what we did
Measuring demand, capacity activity and queue Why is it important to understand the four measures of demand, capacity, activity and queue? To identify the bottleneck or constraint in the care process To increase capacity at the stage of the process where it will create the greatest outcome To reduce inappropriate demand to the constraint To redesign services or plan services
Setting Intent Achieving the target without missing the point What does good look like? Reduced LTC progression Reduced institutionalisation Increased independence Reduced ED attendances and emergency admissions Reduced occupancy of baseline adult non-elective beds Institute of Medicine - Quality Chasm 1. Safety avoid injuries 2. Effectiveness evidence based care 3. Patient centeredness 4. Timeliness avoid harmful delays 5. Efficiency avoid waste 6. Equity prevent quality differences
Data vs Intelligence Activity vs Demand : capacity analysis Predictive modelling Averages vs variance Point prevalence vs run charts/spc Response to variance Special cause vs Common cause Capability assessment For strategic planning, monitoring impact of projects, and operational management.
A whole system perspective Focus on CDM and more effective responses to urgent care needs ACS condition management General Practice & GP OOH Clear operational performance framework and integrated in to primary care Community Support Improved integration with primary care responders Ambulance Service & GP OOH Front load senior decision process incl primary care A+E MAU/SAU/ Short Stay Inpatient Wards Health Promotion Discharge Process Optimise ambulatory emergency care Information flow converting the unheralded to the heralded Redesign to left shift LOS Preventative/ Predictive care Disease management Managed populations Alternatives to acute admission settings Alternative access for diagnosis Alternative settings for therapy Alternative sites for discharge Alternative sites for readmission
Engaging GPs Sensible data in graphical form Enable practices to rank themselves Non-elective cost by HRG chapter Use of OOH Predictive modelling PARR ++, Combined Predictive Model, HUM, EARLI Focus for PBC Same day care in general practice increasing focus
Urgent Care in Primary Care 12 Recommendations Access and responsiveness Understanding capacity and demand Assessment and response Standards and quality Integration Information systems eg OOH With community services
Roland M BMJ 2012. Preventing Emergency Admissions excessive focus on frequent flyers? Does current GP consultation model and QOF allow comprehensive assessment/anticipatory care etc in older people with complex needs?
Admitted Acute Care - Required Actions Identify the drivers Quality IOM 6 domains Create the tension for change Governance and leadership Structure and Behaviours Create the vision Identify added value Alignment for delivery Understand the flow streams Demand, Capacity and Variability Standardise the processes Measure for success - publish Outcome, process and balancing
Reasons/Excuses for not changing Our LOS is OK Flaw of averages How are average LOS calculated? Our patients are different Not believing the data Simple solution just compare yourself with yourself are we improving enough outliers and extra beds? We re a Teaching Hospital So what! The problem is with someone else: Social services Care Homes Diagnostics The patients ie complex elderly - is blaming the patients a good idea? Result = Safer patient care is compromised
Using Data to Drive Improvement If you cannot measure it, you cannot improve it Lord Kelvin, 1824-1907 Stages of facing reality: The data are wrong The data are right, but it s not a problem The data are right; it is a problem; but it is not my problem I accept the burden of improvement Berwick D. Qual Saf Health Care 2003;12(S1):2-6
Risks of Hospital Over-crowding Patient flow is not just about productivity and efficiency its about patient safety. 90%+ of in-hospital deaths occur in the nonelective pathway. The majority of avoidable deaths occur in this pathway. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006; 184:208 12
Beds occupied = The Queue of unfinished work! A bed is where a patient waits for the next useful thing to happen The importance of the hard red line Aim Reduce Acute beds occupied to SPC mean of 600 or less + reduce crude in-hospital mortality rate by 10% + a fall in SCHMI by 31 st March 2012 Process measure The whole system action plan etc etc ie holding the system to account not just the acute sector. Balancing Deliver a decrease in Long term care ie more patients returning to live at home. No increase in 30 day re-admission rate
Care Coordination The health system delivered the required care, but was it in a time frame that suited the patient, carer or staff? Wait Care Wait Care Wait Care Wait By reducing the waiting time overall LOS is reduced without changing the clinical care received by the patient
Adding value for emergency admissions 1. Timely senior assessment 2. Timely case management plan What, where, when, and communication 3. Timely delivery of inputs Diagnostics Interventions 4. Maintaining the tempo Daily review against plan
Balancing Measures Unintended consequences Building a Cascade of Measures L 1 Board & CEO L 2 Service Line Outcome High level eg death, harm etc Process + Outcome L 3 Microsystems: Units, Depts L 4/ 5 Physician & Patient Process (+ Outcome) Individual Process Metrics Adapted from Lloyd & Caldwell
Delivering the Added Value The Process Internal professional standards Standardised documentation Timeliness of assessments, decisions and treatment Timeliness of diagnostics Definition of responsibilities Senior clinical team Managerial team Support services Measurement for improvement Outcome, process and balancing Make visible share and publish Improve design, peer support, escalation
Understanding Demand ED Attendance Admitted and Not Admitted Aim reduce emergency admission from ED to an SPC mean of < 40 per day Process Deliver S+T, RAT, + Intermediate care + Mental Health improvements Balancing 7 day re-attendance and 30 day re-admission
Understanding Demand ED arrival times by day of the week For ease I have used the average, for planning strategic, tactical and operational you would use the 85 th centile of the variance Erlang s Rule
Flow within the ED Where is the problem non-admitted patients?
Flow within the ED Where is the problem admitted patients?
Emergency Department Setting the Standards Internal clock setting, floor management + visual display Time to stream/triage Time to medical assess Time to Clinical Decision Time to dispersal admitting team responsibility Stream management See and Treat - minors RAT/STARR with SIFT Observation/CDU/SSA protocol driven Aiming for single piece flow Treatment unit vs Triage unit Referral protocols + Direct admissions Inward vs outward looking integration with community
EKHUFT NEL In-Day Bed Swing
Trust NEL Admissions and Discharges Demand and surrogate for capacity Aim Reduce emergency admissions by 20 by 31 st March 2012 Processes RAT in A+E, 1 0 Care improvements, improved EoL care etc Balancing - prevent any increase in institutional care
Consequences of admissions & discharges variation mismatch Backlog guaranteed: Patients stored in Assessment Units A&E flow compromised Patients to the wrong wards Outliers Quality Mortality and harm events Patient and staff experience Additional Cost: Overtime, locum, agency and opening wards
Traditional Model for Acute Care GP referrals Handover Short Stay Unit Social care A+E Referrals MAU - Decision to admit Handover Handover Specialist units Home D+T - OPA IC Handover Churn Handover
Assessment Units/ Admitting Specialty Team Setting the Standards Internal clock setting, floor management + visual display Time to stream +/_rapid senior assess and treatment STAT/RAT Process Southampton/Nottingham Time to medical assess and decision support diagnostics Time to Senior Clinical Decision (Consultant) 80% of admissions < 3 hrs, last 20% < 12 hrs Use of evidence based algorithms timelines to treatment Standardising the clinical decision Single piece flow vs batch processing Virtual/real Merger with ED Team
What Constitutes a Senior Clinical Decision Effective senior clinical decision at point of entry being there!: 1 o Diagnosis (or differential) Co-morbidity diagnoses + functional/social problems Case management plan: ZLOS - 1 o care/ic/sc/opa/joint care (Teams walls) Non ZLOS: Why admission required monitoring/interventions Investigations/interventions not just what but when and make it happen! Clinical criteria for discharge + Expected discharge date Stream by LOS see later What to expect post-discharge recovery + follow up
Expected Date of Discharge and Clinical Criteria for Discharge Using EDD and clinical criteria for discharge to support Care Coordination. When setting an EDD do not build in the delays that exist within the system (clinical length of stay only) EDD can be changed for (real) clinical reasons only EDD is a coordination target Set the clinical (incl functional) criteria for discharge Communicate Plan, EDD and Criteria for discharge Creating the expectation Clinical Team Patient and family
Improving Flow in In-patients Remove redundant steps Point of entry decision making team at front of house Handover = delayed decisions = increased LOS Reduce variation in emergency discharges Reduce internal batching and carve-out Reduce impact of intake and twice weekly ward round processes Visual work space management + Daily Consultant review daily drum beat! Standardisation of processes Segmentation of patient by LOS Principle of lanes on a motorway Different process speed and variation Standardise case management processes where possible
In-Patient Units/Specialty Team Setting the Standards Internal clock setting, floor management + visual display Ownership of the case management plan Flow streams Alignment to the EDD (date and time) Control of who can change the EDD Visual display to facilitate daily board review Planning today + tomorrow Expected discharge rates One stop ward rounds Service response time to ED/Assessment Unit request Role of the Senior Clinician (Consultant) Review of entire bed base daily Managing variance from case management plan Re-enforcing the clinical criteria for discharge A specialty can only be considered a specialty if it can deliver specialty care to all inpatients referred to it on a daily basis.
Discharge Planning Standards To commence on day of admission Aligned to EDD and re-enforce clinical criteria Parallel planning no waiting until medically fit MDT role solutions not just identify the problem Balanced risk No discharge is unsafe statements from MDT Process for changing EDD Can only be changed with direct consultation with the Consultant
Pareto Analysis Complex Cumulative Demand 100% 20 Short Stay 30% 15% 5% of demand: Red stream: Rare Strangers 50% of demand = 7% of types: Green stream: Runners \ 80 0 Sick Specialty Sick General LOS Glenday Sieve
LOS Cumulative Profile Excl Paeds, Obstetrics, Midwifery, Zero LOS Colchester %OBD <50% = 3 midnights 10.1% <80% = 11 midnights 36.6% <95% = 28 midnights 70.9% >95% 29.1%
Number of patients Managing the Streams Identify the stream Short stay Sick specialty Sick Frail Complex Allocate early to teams skilled in that stream 250 200 150 100 50 Short stay manage to the hour Maximise ambulatory care Clarity of specialty criteria Specialty case management plan at Handover no delays Green bed days vs red bed days Minimise handover Decompensation risk Early assertive management Green bed days vs red bed days Complex needs how much is decompensation? Detect early and design simple rules for discharge 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 Length of stay (days)
Zero LOS Discharges - Trust Excl paediatrics, midwifery and obstetrics Aim Increase zero LOS Process deliver AEC Balancing Reduce overall NEL admissions
2 midnights or less LOS Discharges - Trust Aim Increase short stay discharges Process deliver AEC + short stay review process Balancing Reduce overall NEL admissions
In-Patients with LOS 14 days or more Aim Reduce I/P with LOS 14 + to 75 or less by 31 st March 2012 Process Early identification of at risk group, CGA, early supported discharge schemes Balancing no increase in institutional care aim for a reduction in over 75s in Long term Care
Integrated Emergency Needs Assessment Service RAT/STAT Model Of Acute Care Handover = Handoff = Increased LOS Sick General/ Complex discharges detect early Social care Stabilisation unit = AMU Ambulatory and Short Stay Unit Home D+T - OPA Small Specialist units IC Discharge plan and case management Measuring Standards Publicise Performance