Key priorities to drive and deliver sustainable improvements Vincent Connolly Clinical Lead ECIST

Emergency Care is a ‘wicked problem’ A social or cultural problem that is difficult or impossible to solve because: of incomplete or contradictory knowledge; of the number of people/opinions involved; of the large economic burden; and of the interconnected nature of this and other problems

Russell L. Ackoff wrote about complex problems as: "Every problem interacts with other problems and is therefore part of a set of interrelated problems, a system of problems…. I choose to call such a system a mess."

What standards do you set for yourself and how do you hold others to account?

Care Coordination The health system delivered the required care, but was it in a time frame that suited the patient, carer or staff ? 5

Whole system approaches are vital if we are to deliver quality healthcare

Average demand = Average capacity Variation mismatch = queue time Demand Capacity Can’t pass unused capacity forward to next week Reducing waiting times in the NHS: is lack of capacity the problem? Bevan et al Clinician in Management (2004) 12: 8

When do medical patients arrive?

Organise beds to improve patient flow Arrange beds around patient streams: Clinical Decision Unit (CDU) / Ambulatory Emergency Care (AEC), Acute Assessment Unit (AAU), short stay, specialty, complex discharge Minimise handovers Combat outliers

New medical model for urgent care patients All non elective activity at the 85th percentile

So How Many Beds? (50 Assessments and <40 patients sleeping over) Estimated Requirement Assessment 16-20 spaces Short Stay 60 beds Specialty total @ 10 nights = 200 @ eight nights = 160 @ seven nights = 140 @ six nights = 120

What type of system?

Admit – but where? Decision to admit Acute Bed Pool two nights Stroke Unit Respiratory Unit Gastro- Intestinal Unit Acute Rehabilitation Unit Decision to admit Acute Bed Pool two nights Metabolic Unit Critical care Cardiac Unit

‘In-reach’ Case Management Stroke Unit Respiratory Unit Gastro- Intestinal Unit Acute Rehabilitation Unit Decision to admit Acute Bed Pool two nights Metabolic Unit Specialist “in-reach” Critical care Cardiac Unit

Outreach Model of Care PCT Acute Bed Pool Decision to admit two nights Stroke Unit Respiratory Unit Gastro- Intestinal Unit PCT Acute Rehabilitation Unit Acute Bed Pool two nights Decision to admit A&E Metabolic Unit Critical care Cardiac Unit

The right people are more important than the right system as long as it is Well described Addresses patient care requirements Everybody understands their role Appropriate support from other services Location is fit for purpose Adequately scoped Supported by staff

Managing the Streams Identify the stream Number of patients Short stay Sick specialty Sick general Complex Allocate early to teams skilled in that stream 250 Short stay – manage to the hour Maximise ambulatory care 200 Clarity of specialty criteria Specialty case management plan at Handover – no delays Green bed days vs. red bed days Number of patients 150 Minimise handover Decompensation risk Early assertive management Green bed days vs. red bed days 100 Complex needs – how much is decompensation? Detect early and design simple rules for discharge 50 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)

Pareto Analysis 30% 20 80 50% of demand = 7% of types: Green stream: ‘Runners’ \ 15% 5% of demand: Red stream: Rare Strangers Sick Specialty 100% Cumulative Demand LOS Sick General Short Stay Complex Glenday Sieve

LOS Cumulative Profile Excl Paeds, Obstetrics and Midwifery, Zero LOS ANHST Top 25 50% = 3 midnights 2 midnights 80% = 10 midnights 7 midnights 95% = 29 midnights 23 midnights

Cumulative OBD by LOS Excl Paeds, Obstetrics and Midwifery , Zero LOS ANHST %OBD <50% = 3 midnights 10.8% <80% = 10 midnights 35.3% <95% = 29 midnights 69.4% >95% = >29 midnights 30.6%

Focus on discharge Consistently prioritising discharge activities can significantly reduce length of stay in elective or emergency clinical care pathways. Prioritising discharge activities only when beds are full may have little impact on patient throughput or average length of stay. Increasing beds may increase length of stay with no benefit to patient throughput. Simulation of patient flows in A&E and elective surgery Discharge Priority: reducing length of stay and bed occupancy Michael Allen, Mathew Cooke & Steve Thornton, Clinical Systems Improvement 2010

Focus on discharge Every patient should be reviewed every day by a senior decision maker Use expected date of discharge (EDD) to support case management for all inpatients Ensure all patients have criteria for discharge Implement morning check-outs so that patients are ‘home for coffee’ Focus on early supported discharge

Which type of doctor? Acute Physician General Physician Specific training Focus on acute med Assessment & 1st 48 hours Will develop acute med Out of hours Generic training Holistic approach Long ward rounds Office hours

The doctor needs to have: Team worker Humility Discipline Measures performance Service improvement Challenges the orthodoxy Accepts and embraces peer challenge Concerned about quality not volume Can describe the system Builds service around the needs of patients

Redesign Focus on decisions, tasks and workflows to optimise care Sort out the high variation Reconfigure the supporting infrastructure to match the redesigned clinical processes Design structures and processes to help learning from daily work Fixing Healthcare from Inside and Out, Harvard Business Review

Does daily senior review work? Twice weekly consultant ward rounds compared with twice daily ward rounds Impact: Over study period, no change in length of stay on ‘control’ wards Average length of stay (ALOS) on study wards fell from 10.4 – 5.3 The impact of twice-daily consultant ward rounds on the length of stay in two general medical wards 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 Weston Clinical Medicine 2011, Vol 11, No 6: 524–8

Continuity of care and regular reviews Hospitals with two or more AMU ward rounds per day on weekdays AND admitting consultants working blocks of more than one day had a lower adjusted case fatality rate. Where the admitting consultant was present for more than four hours, seven days per week they had a lower 28 day readmission rate RCP Taskforce 2007

Internal Professional Standards for AAU Time to first review 15 mins Completion of clerk in Two hours Middle grade review in Four hours Consultant Two-three hours day time, 12 hours out of hours Diagnostics within Four hours Referral response half a day

Quality measures Mortality Mortality & morbidity (M&M) meetings 24 hour discharge rate Delivery of Internal Professional Standards (IPS) Readmissions seven days Adverse events A&E flow Patient experience

Admission avoidance & early discharge Strong evidence Weak evidence Admission prevention from nursing homes Ambulatory emergency care (e.g. 60-90% reduction in overnight stays for pulmonary embolism (PE)) Improve urgent access to primary care Intermediate care in-reach to emergency department (ED) and assessment units Assertive case management of frail patients with dementia Continuity of care with a GP Hospital at home as an alternative to admission Assertive case management in mental health Early senior review in A&E Multidisciplinary interventions and tele-monitoring in heart failure Integration of primary and secondary care GPs in ED Walk in centres (WICs) and urgent care centres (UCCs) (unless co-located with EDs with integrated governance) Public education Pharmacist home-based medication review (Unfocussed) intermediate care Community-based case management (generic conditions) Early discharge to hospital at home on readmissions Nurse-led interventions pre- and post-discharge for patients with chronic obstructive pulmonary disease (COPD) Telemedicine (except for heart failure) 31

An example of success No of patients with LoS > 14 days Crude Mortality No of patients with LoS > 14 days A&E - Time to be seen A&E – Wait to treatment time Hospital Falls Ward cardiac arrests 34

The Ten Commandments Ensure timely access and continuity in primary care There should be early senior review of all patients along all parts of the pathway, to maintain the momentum of care – there should be a senior review of every inpatient’s care plan every day Get patients on the right pathways – Concentrate on patient flow Work together across the whole system to systematically and predictably – implement internal professional standards – to minimise variation Plan and manage capacity to meet demand Avoid unnecessary overnight stays – implement ambulatory emergency care There should be a relentless focus on discharge Develop clear models of care for assertive management of the frail elderly Measure the effect and impact of interventions using SPC and follow up with further improvements Remember this will all be delivered by people so talk, engage, lead, follow & LISTEN