Idealised Design and Modelling of Alternatives to Hospital Care Tom Bowen ORAHS 2010, Genoa, Italy, July 2010

2 Contents Russ Ackoff Whole system approach to healthcare Bed utilisation reviews

3 Professor Russ Ackoff Ackoff & Sasieni, Fundamentals of Operational Research (1968) Redesigning the Future (1974) The Future of Operational Research is Past (JORS, 1979) Resurrecting the Future of Operational Research (JORS, 1979) → Social Systems Science → Systems as a whole → Synthesis not analysis

4 Ackoff quotes “ Complexity is the result of our inability to handle the situation ” “ Could improve part of the system but destroy the whole, by improving the part ” “ The key to interactive planning is … the preparation of an idealised redesign of the system. [But it must be] technologically feasible … and operationally viable ”

5 Ackoff on healthcare (1974 book) “ The general practitioner is gradually disappearing ” “ Kaiser Permanente has grown at a slower rate than the [US] population ” “ Government intervention is … required to create the appropriate demand for … services ” “ A regional system would make it feasible to maintain a central health-data base in which all patient records could be kept ”

6 Pre admission AdmissionDiagnosisTreatmentDischargeRe-admission Social details alone, carers, residence Risk factors: age, drugs, co- morbidities, psychiatric/ dementia, falls Preventative care Disease management Managed populations Source of referral Time Waiting time Route Decision maker Reason for admission Alternatives to admission to acute setting Admission diagnosis Inpatient diagnosis Delays in diagnosis Chronic disease Alternative access for diagnosis Delays in therapy Alternative settings for therapy (especially rehab) Discharge planning Delays in planning Delays in execution Alternative locations for discharge ‘Revolving door’ Avoidable eg. through chronic disease management Alternative locations for readmission The process flow - a ‘rich picture’

7 Bed Utilisation Review A systematic analysis of the delivery of inpatient care through review of clinical records Exploration to see if beds are being used efficiently and effectively Combines: –an objective review using validated criteria –subjective clinical judgement Main tool focuses on acute beds only, but its principles can be extended to non-acute beds

8 Methodology Survey form with ‘AEP’ criteria embedded Point-prevalence on a single day Locally trained surveyors Feedback workshops and scenario modelling Close involvement of local clinicians and managers throughout ‘Whole system’ perspective

9

10

11 Ackoff quotes “ Complexity is the result of our inability to handle the situation ” “ Could improve part of the system but destroy the whole, by improving the part ” “ The key to interactive planning is … the preparation of an idealised redesign of the system. [But it must be] technologically feasible … and operationally viable ”