1. Flow Cost Quality: Transforming non-elective healthcare for older people Tom Downes 4 th March 2014 @sheffielddoc

2. “Right First Time programme is delivering real benefits to patients and the transformation journey across the health and social care system has begun…”

4. Older, frail patients ….part of the NHS must be custom- tuned to their needs. Roy Lilley, The Guardian 29th May 2013

5. A complex system problem

6. 2003 Toyota Corolla

7. Toyota Oobeya (Big Room) How do others design complex systems?

8. First find a room

9. A place to meet

10. The Big Room in Action Physiotherapist gives an account of the test of change to get a patient home on the day they were discharged by the GSM consultant Senior registrar General Manager For Medicine GSM Matron Service Improvement Social Services Manager Community Services manager Physiotherapist Secretary Discharge Liaison

11. Let me introduce ‘George’ 82 years old Lives independently and wants to continue doing so Widowed 5 years ago Has mild dementia Daughter lives locally Losing weight + poor mobility PDSA tests of moving from ‘post take’ to ‘on take’

12. Implementation dates: April 2012 Consultant geriatricians ‘on take’ 7 days per week May 2012 Frailty Unit process initially virtually Frailty Unit opens mid-May

13. Outcome measure: 34% increase in discharge within 1 day

14. Midnight bed occupancy dropped by over 60 beds (no similar change in previous 10 years)

15. Was reduction in bed usage due to reduced admissions? No

16. Balance measure: No increase in readmissions

17. The in-hospital mortality dropped by over 13%

18. Discharge to Assess (D2A) The future hospital will support a system of ‘discharge to assess’ in physiotherapy and occupational therapy. Section 5.20 Future Hospital Report, Royal College of Physicians (September 2013)

19. Implementation dates: April 2012 Consultant geriatricians ‘on take’ 7 days per week May 2012 Frailty Unit process initially virtually Frailty Unit opens mid-May September 2013 Testing of ‘discharge to assess’ from base wards October 2013 Implementation of ‘discharge to assess’ begins

20. Time waiting per patient D2A starts

22. Modern health care is complex Iterative testing and prototyping by front line staff Our patients want timely quality care Timely quality care is cheaper and safer Measure D2A – don’t worry that it’s obvious Our journey has only just started CONCLUSION

23. Thank you Tom.Downes@sth.nhs.uk @sheffielddoc