High quality safe acute services Professor Derek Bell Director NIHR CLAHRC for NW London Imperial College London Chelsea and Westminster Hospital

Characteristics SafeSafe EffectiveEffective Patient CentredPatient Centred QualityQuality InnovativeInnovative PreventionPrevention ProductiveProductive ValueValue

Patient perception of quality by waiting time in acute care

5

30-day adjusted mortality ED Door to medical team time 30-day adjusted mortality P <

7

QUARTERLY A&E WAITING TIMES (ENGLAND ) Percentage less than 4hrs: Seasonally Adjusted

Where are we? Managing the target – delivering high quality careManaging the target – delivering high quality care –Flow –Capacity – demand –Variation –Quality agenda Hitting the target (standard) – missing the pointHitting the target (standard) – missing the point –Gaming Tail gunningTail gunning Boarding but not …….Boarding but not ……. Missing the target (standard) missing the pointMissing the target (standard) missing the point –Gaming –Bringing back old practise –Ignoring quality

NHS London review Upping our game Benchmarking exerciseBenchmarking exercise Review Consultant coverReview Consultant cover –7/7 extended day cover – 12 hours dedicated on site –Twice daily Consultant ward rounds – all patients –All patients in AMU footprint to be seen twice daily –Daily review all wards 7/7 Direct access to AMU from primary careDirect access to AMU from primary care Prompt access to diagnostics and reportsPrompt access to diagnostics and reports

High value High qualityHigh quality –Outcomes –Patient experience –Avoid harm Cost effectiveCost effective –Low variability – consistent –Timely –Right person right staff right place

Elective and emergency Synergy √√√√Synergy √√√√ Competition ----Competition ---- Avoid reactive bed / flow managementAvoid reactive bed / flow management

‘ ‘ System Stress’ – Admission and Discharge Profile for all specialties

Summary We all need to;We all need to; –address the governance issues –control patient flow within the system –ensure we provide continuity of care (rotas and reviews) –design improved 7/7 safer systems –monitor performance and standards –Avoid Safari and Martini –Right place right person first time – all the time

Patient flow groups - must be whole system ! Emergency careEmergency care –Minor injury and illness –Short stay emergency admissions (<48hrs) –In-patient medicine –In-patient surgery Planned carePlanned care –Out-patients –Day case and Short stay –In-patient elective –Complex elective (e.g Intensive Care) –Rehabilitation Not ageist ?Not ageist ?

Findings Systematic review of acute care Scott et al Mortality - 2 hospitals showed significant reductions in all-cause hospital mortality (44% relative reduction over 5 yrs in 1). Length of stay - 4 hospitals showed consistent reduction in LoS of days. Direct discharge rates(DDR): 3 hospitals increased their DDR (24, 48 and 72 hrs). One hospital increased DDR24 by 25%. Downstream Redistribution: 3 hospitals found improved usage of downstream wards. Readmission: No hospital found increased RRs. One hospital halved their RR. Economic: Only economic analysis - saving of 4039 bed days over 12/12, resulting in estimated cost benefit of € Patient and Staff Satisfaction: One hospital found near universal satisfaction with new system. Other found mixed feelings, especially amongst nursing staff who reported much higher levels of stress. Multi-professional teams better