Paul Walley Associate Professor Warwick Business School Redesigning Emergency Care Lessons from the UK

2Warwick Business School Introduction The UK government applies a “4 hour target” journey time for all patients attending A&E departments A&E departments’ performance has improved from 65% target achievement (2001) to 96% in 2005/6 A key catalyst of the improvement was the Emergency Services Collaborative which applied “whole system process redesign” to all 200 sites in England with 24-hour A&E departments Work is now being done to repeat this improvement in Scotland This presentation summarises some of the technical lessons we have learned during the programmes

3Warwick Business School 1. Really Understand Demand Don’t confuse demand with activity Activity: is a significantly modified measure for demand often “double-counts” demand includes “failure demand” - for example rework Patient is ill No space at GP Phones NHS Direct

4Warwick Business School Demand varies over time for a number of reasons: Demand varies by 1.Day of week 2.Weather related 3.Special cause events 4.Random factors BUT Healthcare is arguably one of the least seasonal services we know

5Warwick Business School Demand 2. Develop the Right Capacity Plans Capacity ?

6Warwick Business School What is the relationship between capacity, demand and queue length?

7Warwick Business School Utilisation0%100% Queue length 0 High

8Warwick Business School Server Queue type AQueue type B

9Warwick Business School 3. Demand variation is introduced by the system…

10Warwick Business School 3. … and is amplified by supply chain effects

11Warwick Business School 4. Don’t cluster demand by symptom… Minor Patients “Off Legs” Respiratory Distress Elderly Care Abdominal Pain Chest Pain

12Warwick Business School 4. … instead “Think Process” AssessTreatDischargeAssess Investigate/ Observe Transfer to MH care Assess Admit to medical ward Investigate/ Observe TreatDischarge Assess Admit to surgical ward Investigate/ Observe TheatreDischarge Assess Investigate/ Observe Discharge Treat

13Warwick Business School ReceptionTriageAssessTreatDischarge Wait Reception Wait Assess, treat & discharge a) The conventional model with 4 in-process queues b) See & Treat (one in-process queue) 5. Design to absorb variation (and eliminate waste!)

14Warwick Business School 6. Look at capacity yield losses About half of A&E target breaches are due to lack of bed availability BUT Beds are not usually the true bottleneck Why is this patient still in hospital? 1.Responding to treatment but still poorly (60%) 2.Not seen a doctor yet 3.Successfully treated but given another disease 4.Waiting for tests/treatment 5.Waiting for results of tests 6.Waiting for someone to discharge him 7.Waiting for TTOs (drugs) 8.Waiting to see OT/Physio 9.Staying for meal (nothing at home in fridge) 10.Waiting for relatives to collect (after work) 11.Waiting for other transport 12.Going home tomorrow 13.Complex discharge (social services)

15Warwick Business School Test Question: Has this investment worked? You have spent £2m (capital) on an new “Medical Assessment Unit. The staff costs are £2m p.a. A&E target achievement was measured 1 month before opening and 1 month after: % Major patients admitted or discharged within 4 hours

16Warwick Business School 7. Use time series data (SPC) to measure performance Avoid “two-point comparisons” as they disguise system behaviour MAU opens MAU fills Use SPC to:Monitor and Control a process Measure the effect of changes made Look at system behaviour

17Warwick Business School These peaks occur when there are more than 2 pts with fractured neck of femur on the ward This run of seven points above the mean suggests that the process has changed – possibly due to the increased use of day surgery Source: David Tomlinson LOS data – 80% shorter LOS SPC makes the impact of changes very obvious

18Warwick Business School Summary The improvement of emergency care is a whole system problem The first challenge is to understand true demand Healthcare introduces most demand variation, rather than suffers from adverse seasonality System redesign practices can be used to reduce (sometimes eliminate) built-in delays