1. Key priorities to drive and deliver sustainable improvements
Vincent Connolly
Clinical Lead ECIST

2. Emergency Care is a ‘wicked problem’
A social or cultural problem that is difficult or impossible to solve because:
of incomplete or contradictory knowledge;
of the number of people/opinions involved;
of the large economic burden; and
of the interconnected nature of this and other problems

3. Russell L. Ackoff wrote about complex problems as: "Every problem interacts with other problems and is therefore part of a set of interrelated problems, a system of problems…. I choose to call such a system a mess."

4. What standards do you set for yourself and how do you hold others to account?

5. Care Coordination
The health system delivered the required care, but was it in a time frame that suited the patient, carer or staff ? 5

7. Whole system approaches are vital if we are to deliver quality healthcare

8. Average demand = Average capacity Variation mismatch = queue
time
Demand
Capacity
Can’t pass
unused capacity
forward to next week
Reducing waiting times in the NHS: is lack of capacity the problem?
Bevan et al Clinician in Management (2004) 12: 8

9. When do medical patients arrive?

10. Organise beds to improve patient flow
Arrange beds around patient streams:
Clinical Decision Unit (CDU) / Ambulatory Emergency Care (AEC), Acute Assessment Unit (AAU), short stay, specialty, complex discharge
Minimise handovers
Combat outliers

11. New medical model for urgent care patients All non elective activity at the 85th percentile

12. So How Many Beds? (50 Assessments and <40 patients sleeping over)
Estimated Requirement
Assessment
16-20 spaces
Short Stay
60 beds
Specialty total
@ 10 nights = 200
@ eight nights = 160
@ seven nights = 140
@ six nights = 120

13. What type of system?

14. Admit – but where? Decision to admit Acute Bed Pool two nights
Stroke Unit
Respiratory Unit
Gastro- Intestinal Unit
Acute Rehabilitation Unit
Decision to admit
Acute Bed Pool
two nights
Metabolic Unit
Critical care
Cardiac Unit

15. ‘In-reach’ Case Management
Stroke Unit
Respiratory Unit
Gastro- Intestinal Unit
Acute Rehabilitation Unit
Decision to admit
Acute Bed Pool
two nights
Metabolic Unit
Specialist “in-reach”
Critical care
Cardiac Unit

16. Outreach Model of Care PCT Acute Bed Pool Decision to admit two nights
Stroke Unit
Respiratory Unit
Gastro- Intestinal Unit
PCT
Acute Rehabilitation Unit
Acute Bed Pool
two nights
Decision to admit
A&E
Metabolic Unit
Critical care
Cardiac Unit

17. The right people are more important than the right system as long as it is
Well described
Addresses patient care requirements
Everybody understands their role
Appropriate support from other services
Location is fit for purpose
Adequately scoped
Supported by staff

18. Managing the Streams Identify the stream Number of patients
Short stay Sick specialty Sick general Complex
Allocate early to teams skilled in that stream
250
Short stay – manage to the hour
Maximise ambulatory care
200
Clarity of specialty criteria
Specialty case management plan at
Handover – no delays
Green bed days vs. red bed days
Number of patients
150
Minimise handover
Decompensation risk
Early assertive management
Green bed days vs. red bed days
100
Complex needs – how
much is decompensation?
Detect early and design
simple rules for discharge 50 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59
Length of stay (days)

19. Pareto Analysis 30% 20 80 50% of demand = 7% of types:
Green stream: ‘Runners’ \
15%
5% of demand:
Red stream: Rare Strangers
Sick Specialty
100%
Cumulative Demand
LOS
Sick General
Short Stay
Complex
Glenday Sieve

20. LOS Cumulative Profile Excl Paeds, Obstetrics and Midwifery, Zero LOS
ANHST Top 25
50% = 3 midnights 2 midnights
80% = 10 midnights 7 midnights
95% = 29 midnights 23 midnights

21. Cumulative OBD by LOS Excl Paeds, Obstetrics and Midwifery , Zero LOS
ANHST %OBD
<50% = 3 midnights 10.8%
<80% = 10 midnights 35.3%
<95% = 29 midnights 69.4%
>95% = >29 midnights 30.6%

22. Focus on discharge
Consistently prioritising discharge activities can significantly reduce length of stay in elective or emergency clinical care pathways.
Prioritising discharge activities only when beds are full may have little impact on patient throughput or average length of stay.
Increasing beds may increase length of stay with no benefit to patient throughput.
Simulation of patient flows in A&E and elective surgery Discharge Priority: reducing length of stay and bed occupancy
Michael Allen, Mathew Cooke & Steve Thornton, Clinical Systems Improvement 2010

23. Focus on discharge
Every patient should be reviewed every day by a senior decision maker
Use expected date of discharge (EDD) to support case management for all inpatients
Ensure all patients have criteria for discharge
Implement morning check-outs so that patients are ‘home for coffee’
Focus on early supported discharge

24. Which type of doctor? Acute Physician General Physician
Specific training
Focus on acute med
Assessment & 1st 48 hours
Will develop acute med
Out of hours
Generic training
Holistic approach
Long ward rounds
Office hours

25. The doctor needs to have:
Team worker
Humility
Discipline
Measures performance
Service improvement
Challenges the orthodoxy
Accepts and embraces peer challenge
Concerned about quality not volume
Can describe the system
Builds service around the needs of patients

26. Redesign Focus on decisions, tasks and workflows to optimise care
Sort out the high variation
Reconfigure the supporting infrastructure to match the redesigned clinical processes
Design structures and processes to help learning from daily work
Fixing Healthcare from Inside and Out, Harvard Business Review

27. Does daily senior review work?
Twice weekly consultant ward rounds compared with twice daily ward rounds
Impact:
Over study period, no change in length of stay on ‘control’ wards
Average length of stay (ALOS) on study wards fell from 10.4 – 5.3
The impact of twice-daily consultant ward rounds on the length of stay in two general medical wards
No deterioration in other indicators (readmissions, mortality, bed occupancy)
The impact of twice-daily consultant ward rounds on the length of
stay in two general medical wards
Aftab Ahmad, Tejpal S Purewal, Dushyant Sharma and Philip J Weston
Clinical Medicine 2011, Vol 11, No 6: 524–8

28. Continuity of care and regular reviews
Hospitals with two or more AMU ward rounds per day on weekdays AND admitting consultants working blocks of more than one day had a lower adjusted case fatality rate.
Where the admitting consultant was present for more than four hours, seven days per week they had a lower 28 day readmission rate
RCP Taskforce 2007

29. Internal Professional Standards for AAU
Time to first review 15 mins
Completion of clerk in Two hours
Middle grade review in Four hours
Consultant Two-three hours day time, 12 hours out of hours
Diagnostics within Four hours
Referral response half a day

30. Quality measures Mortality Mortality & morbidity (M&M) meetings
24 hour discharge rate
Delivery of Internal Professional Standards (IPS)
Readmissions seven days
Adverse events
A&E flow
Patient experience

31. Admission avoidance & early discharge Strong evidence Weak evidence
Admission prevention from nursing homes
Ambulatory emergency care (e.g % reduction in overnight stays for pulmonary embolism (PE))
Improve urgent access to primary care
Intermediate care in-reach to emergency department (ED) and assessment units
Assertive case management of frail patients with dementia
Continuity of care with a GP
Hospital at home as an alternative to admission
Assertive case management in mental health
Early senior review in A&E
Multidisciplinary interventions and tele-monitoring in heart failure
Integration of primary and secondary care
GPs in ED
Walk in centres (WICs) and urgent care centres (UCCs) (unless co-located with EDs with integrated governance)
Public education
Pharmacist home-based medication review
(Unfocussed) intermediate care
Community-based case management (generic conditions)
Early discharge to hospital at home on readmissions
Nurse-led interventions pre- and post-discharge for patients with chronic obstructive pulmonary disease (COPD)
Telemedicine (except for heart failure) 31

34. An example of success No of patients with LoS > 14 days
Crude Mortality
No of patients with LoS > 14 days
A&E - Time to be seen
A&E – Wait to treatment time
Hospital Falls
Ward cardiac arrests 34

35. The Ten Commandments
Ensure timely access and continuity in primary care
There should be early senior review of all patients along all parts of the pathway, to maintain the momentum of care – there should be a senior review of every inpatient’s care plan every day
Get patients on the right pathways – Concentrate on patient flow
Work together across the whole system to systematically and predictably – implement internal professional standards – to minimise variation
Plan and manage capacity to meet demand
Avoid unnecessary overnight stays – implement ambulatory emergency care
There should be a relentless focus on discharge
Develop clear models of care for assertive management of the frail elderly
Measure the effect and impact of interventions using SPC and follow up with further improvements
Remember this will all be delivered by people so talk, engage, lead, follow & LISTEN