Analysing systems to perform– what do leaders need to know? Russell Emeny Director, Emergency Care Intensive Support Team ECIST

Do you agree? Metrics are essential tools in managing urgent and emergency care We manage what we measure We need a comprehensive suite of excellent metrics to be able to manage the urgent and emergency care system effectively

Current metrics don’t fit the bill: A&E 4-hour standard Delayed transfers of care Ambulance response times And many more……….

4-hours has had some success and retains some support as a measure of system flow (98%) (95%)

“Introduction of the 4-hour rule in Western Australia led to a reversal of overcrowding in….emergency departments that coincided with a significant fall in the overall mortality rate” Medical Journal of Australia 2012

Crowded emergency departments Retrospective analysis of 694 patients with community acquired pneumonia Delayed delivery of antibiotics in 4 hours ED not crowded – 31% ED overcrowded – 72% Pines JM et al. The impact of emergency department crowding measures on time to antibiotics for patients with community acquired pneumonia. Annals of Emergency Medicine, 2005, 50(5):510-516 Crowded emergency departments Dangerous Correlates with increased length of stay

Delivering targets can be tackled by: Improving processes to deliver the required performance Distorting processes Distorting the numbers …and measuring 4-hours is easy to distort

Distorting the process Normal process Spot the ‘hair cut’ Admissions ward opens: patients thrown in at 3 hours 45 mins. Breaches continue when unit full

The hunt is on!

Keogh Review Looking for metrics that produce signals of problems and signs of effective performance Clinical pathways Patient experience Staff experience

Clinical Pathways Population mortality rates for serious emergency conditions Case fatality rates for serious emergency conditions Emergency admission rates for cases that can be managed outside hospital Unnecessary attenders at A&E: all patients or those arriving by ambulance % referred/not referred from GP /Primary Care Multiple transfers and multiple attendances across the network Existence of (and adherence to) care plans, and access to care plans Supported to manage condition (self-care) and self-management for LTCs Time from first contact to definitive care/senior clinical review Discharge to normal place of residence/back to previous level of function - recovery measures/ Death in place of choice as identified in care plan Availability of out of hours GP appointments Occupancy and system flow

A pause

Economists successfully made the case to spend Euro 5 billion to reduce travel time by 30 minutes But consider…… Add WiFi and free wine, served by really friendly models……. And people will ask for the trains to be slowed down Saving euro 4 billion

Is it possible that we place an overreliance on metrics, numbers, counting and ‘scientific’ thinking?

The rules that govern complex systems are not the same as the rules that govern complicated systems

Health care is a complex adaptive system Collection of parts Share an environment Parts are interconnected Parts can act independently Action by any part may affect the whole

?

Some principles for leading change in a complex adaptive system Think like a farmer, not an engineer Don’t over-plan – outcomes are not predictable Replace rules and regulations with common purpose, values, principles Dump the concept of ‘resistance to change’ – it’s negative and draining Continually reframe the story to attract new supporters Create a social movement

Leaders need to create compelling stories of ‘what good looks like’ to help people connect with them at the level of values and emotions – not just intellect.

What does good look like?

Leaders needs to understand how things fit together – and the really big issues We can then look for metrics that help shape a narrative around the things that really matter

Is the weekend discharge rate a general problem?

Is the weekend discharge rate a general problem? Two processes One hospital?

Where should we focus our efforts?

Two different processes – up-stream / down-stream

Three hospitals in one High capacity Moderate capacity ‘Ology Emergency Out of hours ‘Ology Moderate capacity Low capacity

About increasing the capacity and efficiency of the emergency part of the system Capacity exchange Winning hearts and minds Implementing proven good practice

The SAFER Patient Flow Bundle S - Senior Review, all patients will have a Consultant Review before midday A - all patients will have a planned discharge date (that patients are made aware of) F - flow of patients will commence at the earlier opportunity (by 10am) from assessment units to inpatient wards. Wards are expected to ‘pull’ the correct patient to their ward before 10am E – early discharge, 25% of our patients will be discharged from base inpatient wards before midday. TTO’s (medication to take home) for planned discharges should be prescribed and with pharmacy by 3pm the day prior to discharge R – review, a weekly systematic review of ‘stranded’ patients with extended lengths of stay ( > 10 days) to identify the issues and actions required to facilitate discharge. This will be led by senior leaders within the Trust

Emergency ‘Ology Out of hours High capacity Moderate capacity Emergency ‘Ology capacity capacity Out of hours Moderate capacity

Where should we focus our efforts?

What we recommend Target demand management on frail, older people: General practice response Intermediate care (including rapid response) Care homes Get patients into the right ‘flow stream’ from the outset and avoid outliers Focus on flow beyond the ED: Early senior review Daily senior reviews / board rounds Focus on discharge: SAFER bundle – simple rules day in day out Red and green days Ward round checklists

What we recommend (more) Implement ambulatory emergency care (include surgery) Implement a whole system frailty model with early CGA, rapid turnaround, discharge to assess Extend services into the evening, not just the weekend

Most studies suggest that admissions can be avoided in 20-30% of >75 year old frail persons  “Avoiding admissions in this group of older people depended on high quality decision making around the time of admission, either by GPs or hospital doctors. Crucially it also depended on sufficient appropriate capacity in alternative community services (notably intermediate care) so that a person’s needs can be met outside hospital, so avoiding ‘defaulting’ into acute beds as the only solution to problems in the community”. Mytton et al. British Journal of Healthcare Management 2012 Vol. 18 No 11

Time of admission Monday Tuesday Weds Thursday Friday Saturday Sunday 3-day LOS difference between 9am and 9pm admissions Midday Midnight Midday Midnight Midday Midnight Midday Midnight Midday Midnight Midday Midnight Why? Late admissions less likely to have a consultant review; more likely to ‘board’; more likely to have a care plan from junior doctor; more likely to be admitted from a crowded A&E

Boarding: 50% higher mortality adds 2 days to length of stay Ave LoS Readmissions Mortality Notes 7 day 30 day Non-Boarded 2.3 4.6% 7.5% 1.4% 2.8% Boarded 6.5 11.0% 2.0% 4.2% Wards boarding pts out 4.2 4.8% 10% 2.5% 3.7% Highest no of patients Mortality on wards that board patients out is 30% higher than on those that don’t

? Often feels like we run out of capacity here Typical daily acute emergency inpatient flow. Daily mismatch between flow and available beds ? Often feels like we run out of capacity here

Twice weekly consultant ward rounds compared with twice daily ward rounds Impact: Average length of stay on study wards fell from 10.4 – 5.3 No deterioration in other indicators (readmissions, mortality, bed occupancy) The impact of twice-daily consultant ward rounds on the length of stay in two general medical wards Aftab Ahmad, Tejpal S Purewal, Dushyant Sharma and Philip J WestonClinical Medicine 2011, Vol 11, No 6: 524–8 During a perfect week there are twice daily senior reviews……what happens?

Reduce variation in ward rounds Dr Gordon Caldwell

Avoid ‘bedded’ discharge destinations where possible – we should ‘discharge to assess’. Home Care Home Care home Hospital 12.3 days 14 days 31.7 days Initial residence Discharge location Hospital average length of stay FTN Benchmark March 2012

But everyone knows we need more of these…

People do not always think rationally Availability heuristic leads to – ‘we need more beds’ Optimism bias leads to – ‘our pet scheme will work’

So what about metrics? Choose metrics that engage colleagues in a narrative of quality and safety (like ‘boarders’) Avoid upping the ante or people will distort numbers or processes to demonstrate ‘achievement’ Keep things simple Encourage the use of run charts, not ‘trajectories’

……. spreading innovations… …….spreading innovations…..is essentially a social process that hinges on effective person-to-person communication rather than technological solutions or indeed the use of incentives and penalties (Gawande 2013). …people follow the example of those they know and trust………there is no alternative to creating time and opportunities for credible leaders and innovators to offer time and support to those seeking to bring about improvements in care. Reforming the NHS From Within. Chris Ham, Kings Fund, 2014

Thanks