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Refining and Redefining Emergency Flows
Dr Veronica Devlin Programme Lead Service Improvement and Clinical Governance Emergency Care
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Defining flows Resus <5% Majors 40-45% Minors 55-60%
Admitted, by specialty Assessment majors Minors Planned returns Ward work
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Patient Numbers Accident & Emergency March-May 2009 (3months) NHSL Overall
No Follow Up # 28,302 54.0% Avg. 107 min GP follow up A&E # 7,912 15.1% Avg. 113 min Minors , % Medical , % 52,398 Acute ass. 7, % Surgical , % Emergency Receiving Unit # 7,973 15.2% Avg. 144 min Deaths % Admission # 5,190 9.9% Avg. 137 min Other* # 3,021 5.8% Avg. 81 min *e.g. Other Hospitals, Primary Care Emergency Centre
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Theory…..
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Practice….
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History of specialty 3 ED’s Fewer middle grades Recruitment issues Retention issues Casemix challenge Access block Audit Scotland Quality standards Delivery
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Theory….
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Practice…
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Lean in emergency flow
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Lean principles Specify value Map the value stream (patient flow)
Implement flow Establish pull where you can’t flow Work to perfection Voice of the customer
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Lean tools Standard work Standard operating procedures
Managing variation Metrics Dashboards
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all others must bring data
In God we trust all others must bring data
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Deming You can’t manage on visible figures alone
Figures on the most important areas of management may be unknown or unknowable, and successful managers must nevertheless manage those areas.
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Vital Signs - measurement
ED TTFA DNW’S Unplanned returns Planned returns Delays to care
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Vital Signs - measurement
Admission/discharge balance Discharges before noon Diversions 8 and 12 hour delays to care Boarders Additional beds Delayed discharges Length of stay on Medical Receiving Unit Total hospital length of stay Diversions Cancelled electives due to lack of capacity Surge capacity Use of off site beds
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Monklands Minors flow Majors pitstop ACE GP assessment bay
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minors
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Minors flow Monklands Maintaining operation Timing of stream operation
Staffing Operational set up Monitoring Follow up arrangements
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Patients had to go outside after registration
reception store xray Patients had to go outside after registration
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store reception xray Patients’ journey contained within the department – and no compromise in Waiting Room space
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Majors Pitstop Proof of concept
Dedicated approach for assessment of majors Negotiated diagnostics Senior decision-making Average tat 102 minutes during trystorm
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Majors pitstop
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GP assessment bay Complete team based assessment Meds rec
Admission avoidance Decide to admit vs admit to decide
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Implement ASSESSMENT BAY and ACE
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Hairmyres STATUS CHANGE
Medical Assessment bay Minors flow CPAU pathway Stroke pathway
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AMRU Dashboard Key Performance Indicators LENGTH OF STAY
Patient moves Before noon am/pm Ward Round Start Times Key Performance Indicators Ward Pull Parent Specialty Mix Porter Response Times Admissions vs. Discharges & Transfers MAB Performance Surge Beds
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Medical Assessment Bay (MAB)
Sustainability Change Detail Consistent staffing, bed availability Ambulance Service/ERC Criteria for access. 4 Trolley bay in AMRU for the review of GP referred medical patients between 9am and 7pm weekdays) Key Performance Indicators 25% of patients Discharged from MAB
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Medical Assessment Bay (MAB)
Change Detail Sustainability Consistent staffing, bed availability ? Senior Decision Maker availability in MAB 4 Trolley bay in AMRU for the review of GP referred medical patients between 9am and 7pm (weekdays) Was 9% Now 18% admitted in <2hrs Key Performance Indicators MAB journey time 37 mins less than A&E MAB TTFA 30 mins less than A&E From 48% to 33% Admitted between 210 & 240 mins
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Daily Dashboard Change Detail Sustainability Visual management
Target driven Updated and reviewed daily Also for surgical and medical flow Monitors individual ward performance Daily Dashboard
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Positives Excellent clinical engagement Data driven
Perceive the service from customer viewpoint But….
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Reshaping Emergency Medicine
Clinical Director Consultant appointments Review of skillmix Standard operating procedures Quality Standards Safety Brief Roles and Responsibilities redefined
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Consolidate core service
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Non core ED work
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