1. Redesigning Acute Care for Older People: The Start of Sheffield’s Journey
Tom Downes MB BS, MRCP, MBA, MPH (Harvard)
Clinical Lead for Quality Improvement
Sheffield Teaching Hospitals
The Health Foundation / IHI Quality Improvement Fellow
28th November 2012

2. UNSUSTAINABLE Healthcare inflation
4.3% per year over the last 30 years
Driven by technology and expectation
Only 0.4% attributable to ageing
Need to deliver over 20% more care in 5 years’ time
Need to deliver over 50% more care in 10 years’ time
UNSUSTAINABLE
Rises in healthcare spending: where will it end?
Jon Appleby, BMJ 1st November 2012
Rises in healthcare spending: where will it end?
Jon Appleby, BMJ 1st November 2012

3. ‘We must redesign services.
Decisions about service redesign must be clinically led and clinicians must be prepared to challenge the way services - including their own service – are organised.’
Hospitals on the Edge – The time for action
Royal College of Physicians, 13th September 2012

4. Day 2127 as a consultant

5. A ‘system’ problem We have a problem.
A combined health and social care of Sheffield challenge.
This control chart shows the length of stay of consecutive patients discharged over 3 months last year.
Over the whole year, the average length of stay in geriatric medicine was about 20 days.
We have approximately 300 geriatric medicine beds with a length of stay roughly 50% longer than expected for our case-mix.
Last year, our nurses measured that 48% of our inpatients are ‘waiting’ rather than receiving acute hospital care.
This waiting and delay is harmful for older people: infection risk, immobilisation and pressure ulcers, infection risk, falls risk and institutionalisation.
We have set out on a journey to redesign our system for our patients.

6. A complex system problem
We mapped out our processes – they are very complex.

7. 2003 Toyota Corolla

8. How do others design complex systems?
Toyota Oobeya Room
Our system is so complex we realised that we need a methodology to redesign a very complex service.
Modern cars are very complex and involve many different processes and technology. We can see similarities to modern health care which also has many different processes and technology.
We have decided to use a methodology from the car industry that we have translated to healthcare. We do not talk about tyres, engines and petrol. For us it’s about nurses, doctors, therapists and medication.

9. First find a room

10. The Room
We meet regularly in a room set up to share our learning between all our health and social care interprofessional groups.
It was a coffee room that we underused.

11. Board 1: The Business objectives:
GSM weekly bed occupancy
from April 07 with target lines
Board Level
Business objectives
for GSM

12. Board 2: What do these objectives mean for our patients?
A Future State
diagram
Of the GSM
Process as it
evolved
Post-it note comments from stakeholders

13. Board 3: How are we doing against the GSM business and patients objectives?

14. Board 4: High Level GSM Process through the complex health and social care system & Board 5: Real time plan
High Level: Current State Map of the GSM process
Programme Plan
time
April
Each row
presents
the tasks
(yellow post-its)to
be performed
by each
stakeholder
group

15. Tests

16. Let me introduce ‘George’
PDSA tests of moving from
‘post take’ to ‘on take’
Let me introduce ‘George’
We have tested changing the way consultant geriatricians work at the front door. We demonstrated that we can reduce the average time from arrival at hospital to being seen by a consultant geriatrician from about 20 hours to near to 4 hours.
George (not his real name, nor his real picture) was involved in one of our first tests of changing outpatient care. Usually it takes about 3 months for patients to navigate the process of getting from referral by their GP through a first visit, tests and a second visit to see the consultant for a definitive diagnosis.
We tested whether we could deliver that 3 month process in less than 8 hours. George came to see us the next working day after we contacted him and his daughter. From arrival at hospital we did everything including; history, examination, test, physio assessment (he was fitted with a walking stick), consultant review. He left less than four hours after arriving with a letter in his hand documenting everything that had been done with all the results.
He had lunch at home with his daughter. His daughter (who works) was delighted by the way the care was organised.
82 years old
Lives independently and wants to continue doing so
Widowed 5 years ago
Has mild dementia
Daughter lives locally
Losing weight and finding walking more difficult

17. Challenge to UK geriatric medicine traditions:
Split of inpatient / outpatient care
Combined immediate delivery
of specialist MDT care

18. This is a control chart of the demand for specialist geriatric care over 6 months.
We have measured the demand of our service. We know that we have to design to be able to deliver a specialist multidisciplinary assessment including tests to 26 patients per day to be able to meet our demand 80% of the time. We know how important it is to not design for our average of 17 assessments per day as this would mean that half the time we wouldn’t be able to meet the demand and queues would form.

19. Batching patients for ‘Post-take ward round’
Real-time senior specialist review (7/7)
Bedded medical assessment unit could be unnecessary for most geriatric medicine patients

20. Twice weekly senior clinician ward rounds
Daily senior decision capability on every ward

21. MDT planning meetings
Assess needs at home once acute hospital environment no longer adding value

22. Through the testing we have learned that the same nurses, doctors and therapists look after patients regardless of how they are referred to us.
We have measured how fragmented the function of this team is. In our tests, this interprofessional team has to work in 5 different places. This fragmentation makes us less efficient.

23. Porter’s Value Based Design
Integrated Practice Units
Measure Outcome
Bundled Pricing
Integrate across Geography
Expand Excellence
Enabling IT platform
VALUE
What Is Value in Health Care? Michael E. Porter, Ph.D. N Engl J Med 2010; 363: December 23, 2010

24. Implementation headlines:
April 2012
New discharge process from assessment units
Consultant geriatricians ‘on take’ 7 days per week
May 2012
Frailty Unit process initially virtually
Frailty Unit opens mid-May
July 2012
Ambulatory care area for work formerly considered to be outpatient

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

26. Outcome measure: Bed occupancy reduced by over 60 beds

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

28. Would it have happened regardless?
Balance measure:
Would it have happened regardless?

29. Decrease in readmissions
Balance measure:
Decrease in readmissions

30. Balance measure:
Decreased mortality

31. Value Value = Outcome / Cost Return on investment
= Saving – Investment / Investment
= (£3,000,000 - £750,000) – 140,000 / £140,000
= 2,110,000 / 140,000
= 15

32. Not hospital @ home Resources have started to move to the community
Designing and

33. We feel like we are at the bottom of an enormous cliff.
At the start it felt completely insurmountable.
Through testing we have started to find some hand and foot holds to start climbing.
Through the measurement and interprofessional discussions we are beginning to plot a route.
We still have a long way to go.

34. ‘Improvement in health care is 20% technical and 80% human’
Marjorie Godfrey
The Dartmouth Institute

35. Conclusion Modern health care is complex
Iterative testing and prototyping is required
Cooperation between and health and social care is essential
Our journey has only just started 35

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