1. Improving Capacity Management and Patient Flow Chris Stirling Associate Director of Operations NHS Lothian

2. 3 main acute adults sites(2010-11) – RIE – 111,000 attendances (up 3000 from 09-10) – WGH – 35,865 attendances (including MIU) – SJH – 47,766 attendances RHSC – 37,585 attendances

3. Lothian performance

4. EAST Diagnostic visit - March 2010 Many opportunities for improvement in different areas…. Late discharge by hospital sites Mismatch of capacity with demand (beds/staff/sites) Reactive/tactical use of capacity High levels of boarding Lack of pull to downstream beds Internal processes – communication issues Use of information to support improvement Crisis spike – poor for patients and staff

5. Many actions, PDSA’s & changes Refocus on protecting Flow 1 at RIE Front Door areas – matching staffing capacity with demand Introduction of protected Primary Assessment Area Improvement in Older people pathways Improvements to predictor tool Introduction of OPAT/Team 65 (MoE in assessment areas) Change in ED escalation roles (ownership) CAA – medical sweeps/presence Wards – earlier decision making, rapid run-downs Site Emergency Access meetings – new focus Value stream mapping on patient pathways Specialty actions plans

6. Matching capacity and demand

7. One aspect of capacity – system level Problem RIE more pressured than other 2 adult sites Reactive practice of redirecting patients from RIE to WGH/SJH compounding problem SAS activity skewed to RIE away from RIE – affected by variety of factors

9. End of shift – crews crossing town away from WGH to get back to SAS Station for end of shift (near the RIE)

10. Actions Rezoning of GP practices – for GP bed bureau patients to increase activity to WGH away from RIE to reduce unplanned redirection from RIE. Two tranches. LMC involvement. Journey time analysis by EAST SAS development of sub-stations in North Edinburgh SAS partnership working – receiving unit and facilities staff Opening of WGH ARAU overnight to relieve capacity pressure at RIE as Winter response Testing with NHS24 use of scheduled appointments for bony injuries Futher actions still to be resolved for system level capacity changes Bed reprofiling within and between sites and between specialties Further shift of elective activity profile from Mondays to other days Further shift of activity off RIE site Additional developments of ambulatory care Testing different model of specialty handovers to reduce delays Progress with HEAT T10 and alternatives in Primary Care

11. Downstream flows Problem MoE long lengths of stay & delays in transfer from acute sites to downstream sites (Liberton, Royal Victoria, Roodlands, Astley Ainslie) Difficulties in matching capacity and demand between acute sites and downstream sites Lack of awareness / responsiveness (pull)

12. Actions Organisational priority - year long lean pathways work on Older people (general rehab, stroke, orthopaedic rehab, dementia) Multiple Kaizens/workouts. Ongoing focus. Development of expanded community rehab and reablement services to support earlier discharge and pull from hospital/community. Ortho-rehab LOS reduced Establishment of OPAT/Team 65 improving early selection of MoE patients and “pull” from front door areas Improved communication between acute/downstream sites – more reliable matching of capacity with demand 70% increase in throughput on relevant wards since 2009, reduction in LoS Further action using Change Fund

13. LUHD: Daily Emergency Access Report 19227 4-Hour Emergency Access Standard April 2010 Trajecto ry chart target for this Month 98% Date ED* daily attendance Daily 4- hour breaches Breaches for month to date Daily compliance achieved ED* attendance for month to date Compliance for month to date Current number of breaches for this month 835 Max number of breaches for compliance with 4-hour emergency access standard 382 Thu 01-Apr-1062952 91.73%62991.73%Colour Code Fri 02-Apr-10659308295.45%128893.63% 98%Trajectory and above Sat 03-Apr-106584913192.55%194693.27% 95%Below current trajectory position Sun 04-Apr-106534717892.80%259993.15% <95%Remedial performance Mon 05-Apr-107083921794.49%330793.44% Tue 06-Apr-106257228988.48%393292.65% Wed 07-Apr-106256535489.60%455792.23% Thu 08-Apr-105783038494.81%513592.52% Fri 09-Apr-106203141595.00%575592.79% Sat 10-Apr-106261042598.40%638193.34% Sun 11-Apr-10671543099.25%705293.90% Initial Reasons For breaches% Mon 12-Apr-107092545596.47%776194.14%83Clinical exception 0.4% Tue 13-Apr-106261647197.44%838794.38%288Wait for 1st assessment1.5% Wed 14-Apr-106161648797.40%900394.59%220Wait for bed 1.1% Thu 15-Apr-10589449199.32%959294.88%8Wait for diag test start 0.0% Fri 16-Apr-106274153293.46%1021994.79%59Wait for diag test result0.3% Sat 17-Apr-105991354597.83%1081894.96%26Wait for NHS transport 0.1% Sun 18-Apr-106042456996.03%1142295.02% Wait for non NHS transport Mon 19-Apr-106952959895.83%1211795.06%58Wait for specialist 0.3% Tue 20-Apr-106501461297.85%1276795.21%3Wait for treatment to start0.0% Wed 21-Apr-10621862098.71%1338895.37%34Wait for treatment to end0.2% Thu 22-Apr-10595962998.49%1398395.50%56Other (please specify) 0.3% Fri 23-Apr-10556863798.56%1453995.62% No reason recorded Sat 24-Apr-106452165896.74%1518495.67%835 Sun 25-Apr-106581667497.57%1584295.75% Mon 26-Apr-107703070496.10%1661295.76%Total attendances19227 Tue 27-Apr-106443173595.19%1725695.74% Wed 28-Apr-106762075597.04%1793295.79% Thu 29-Apr-106214079593.56%1855395.71% Fri 30-Apr-106744083594.07%1922795.66% Then

14. LUHD: Daily Emergency Access Report 20254 4-Hour Emergency Access Standard April 2011 Trajector y chart target for this Month 98% Date ED* daily attendance Daily 4- hour breaches Breaches for month to date Daily compliance achieved ED* attendance for month to date Compliance for month to date Current number of breaches for this month 571 Max number of breaches for compliance with 4-hour emergency access standard 382 Fri 01-Apr-1167926 96.17%67996.17%Colour Code Sat 02-Apr-11667204697.00%134696.58% 98%Trajectory and above Sun 03-Apr-11734135998.23%208097.16% 95%Below current trajectory position Mon 04-Apr-11762349395.54%284296.73% <95%Remedial performance Tue 05-Apr-116854714093.14%352796.03% Wed 06-Apr-116874618693.30%421495.59% Thu 07-Apr-116921119798.41%490695.98% Fri 08-Apr-116704524293.28%557695.66% Sat 09-Apr-116672426696.40%624395.74% Sun 10-Apr-117241528197.93%696795.97% Mon 11-Apr-117521629797.87%771996.15% Initial Reasons For breaches% Tue 12-Apr-116223032795.18%834196.08%78Clinical exception 13.7% Wed 13-Apr-116022835595.35%894396.03%102Wait for 1st assessment17.9% Thu 14-Apr-11588536099.15%953196.22%200Wait for bed 35.0% Fri 15-Apr-116421037098.44%1017396.36%6Wait for diag test start 1.1% Sat 16-Apr-116261038098.40%1079996.48%44Wait for diag test result7.7% Sun 17-Apr-116721239298.21%1147196.58%16Wait for NHS transport 2.8% Mon 18-Apr-117391540797.97%1221096.67% Wait for non NHS transport Tue 19-Apr-11623841598.72%1283396.77%62Wait for specialist 10.9% Wed 20-Apr-11616942498.54%1344996.85%2Wait for treatment to start0.4% Thu 21-Apr-116541143598.32%1410396.92%29Wait for treatment to end5.1% Fri 22-Apr-11624744298.88%1472797.00%32Other (please specify) 5.6% Sat 23-Apr-116701345598.06%1539797.04% No reason recorded Sun 24-Apr-116761346898.08%1607397.09%571 Mon 25-Apr-11750547399.33%1682397.19% Tue 26-Apr-117201648997.78%1754397.21%Total attendances20254 Wed 27-Apr-116972951895.84%1824097.16% Thu 28-Apr-116293054895.23%1886997.10% Fri 29-Apr-116561155998.32%1952597.14% Sat 30-Apr-117291257198.35%2025497.18% Now

15. Significant issues still remain Performance at RIE still not achieving 98% Crisis spike still present Lowering the water level… …exposes more rocks!