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

2. 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

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

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

5. “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

6. 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):
Crowded emergency departments
Dangerous
Correlates with increased length of stay

7. 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

8. 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

9. The hunt is on!

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

11. 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

12. A pause

13. 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

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

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

17. 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

18. ?

19. 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

20. 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.

21. What does good look like?

22. 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

23. Is the weekend discharge rate a general problem?

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

25. Where should we focus our efforts?

26. Two different processes – up-stream / down-stream

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

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

29. 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

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

31. Where should we focus our efforts?

32. 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

33. 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

34. 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

35. 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

37. 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

38. ? 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

39. 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?

40. Reduce variation in ward rounds
Dr Gordon Caldwell

41. 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

42. But everyone knows we need more of these…

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

44. 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’

45. ……. 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

46. Thanks