1. NHSScotland Event 2015 LEADING INTEGRATION FOR QUALITY A:2 Unscheduled Care – Can We Fix It?

2. 6 Essential Actions to Improving Unscheduled Care: A Systematic Approach Dr Catherine Calderwood Chief Medical Officer, Scottish Government [Day 1] Prof Derek Bell President RCPE & Clinical Lead UC, SG [Day 2] Dr Simon Watkin Consultant Physician, NHS Borders

3. Unscheduled Care…. Can we fix it?

4. 6 Essential Actions to Improving Unscheduled Care The overall aim is to : Improve Patient Care Improve Patient Experience Improve Patient Outcomes

5. Long term trend in A&E performance

6. Multimorbidity is common in Scotland The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions More people have 2 or more conditions than only have 1 There are more people in Scotland with multimorbidity below 65 years than above

7. Attendance and admissions by age https://isdscotland.scot.nhs.uk/Health-Topics/Emergency-Care/Publications/2014-11-25/Attendances_Nov14.xlsx

8. Daily hospital inpatient arrival and discharge profile, Anytown Hospital 1 st Dec 2013 to 1 st Mar 2014

10. The Case For Change Patients – Delays, lying on trolleys for prolonged periods, poor communication, boarding, being diverted/transferred to another hospital and being told they are going home the next day and waiting around all day for their prescription etc. GPs - their referral letter not reaching the hospital team assessing the patient, delay to first assessment/admission and poor discharge communication. ED/Acute Clinicians – over-capacity and delay in bed availability (“perceived lack of whole hospital commitment”) Physicians – Direct admissions without appropriate senior review, not getting the right patients in the right bed, boarding/"safari ward rounds" and diverts/case-by-case transfers. Surgeons – Medical boarding, having to cancel elective cases, having to leave theatre/ward rounds to go to ED. Nurses - receiving patients when they are doing ward/drug rounds, receiving "batches" of really sick patients when they are short of staff/producing another report, boarding patients that they know will add complexity and confusion to their discharge. Managers - Not being able to increase pre-noon or weekend discharge rates, resolve discharge script delays, find solutions whilst doing their "day" job, despite years of trying. Being asked to produce another plan to resolve the problems before close of play/next day/in a week. "Man marking" everything and nothing! 10

11. 6 Essential Actions to Improving Unscheduled Care Empowered Clinically Focussed Hospital Management Hospital Capacity and Patient Flow Realignment Patient rather than Bed Management Medical and Surgical Clinical Processes Targeted 7 day services Ensuring Patients are cared for in their own homes

12. Clinical Leadership & Engagement Triumvirate Site Management Team Operational Management, Medical, Nursing (NMAHP) Whole System communication & real time engagement Patient Quality Huddles Prevent Access Block Escalation Process

13. Discussion point Who are the people in charge of your hospital after 9pm? Who makes decisions On site Off site

14. The Six Essential Actions To Improving Unscheduled Care A way forward

15. 6 Essential Actions to Improving Unscheduled Care Performance Safe, person centred, effective care delivered to every patient, every time without unnecessary waits, delays and duplication Hospital Capacity and Patient Flow Realignment Medical and Surgical Processes arranged to Pull Patients from ED 7 day services Ensuring Patients are cared for in their own homes Clinically Focused and Empowered Hospital Management Patient and Staff Experience Patient rather than Bed Management - Operational Performance To achieve: Improve:By managing: Do these well: Triumvirate Management Clinical Leadership Escalation Safety, Flow Huddles Basic Building Blocks Bed Planning Toolkit Workforce Capacity Toolkit Guided Patient Flow Analysis Patient tracking through System Admission/ discharge prediction Balance capacity & demand Proactive Discharge Management Triage to appropriate assessment Flow through ED Access to Senior Decision Maker Access to Assessment/Diagnostics Smooth admission/ discharge profile Surgical Emergency & Elective Services Integrated SAS Services/ decision support GP/OOH services Living & dying well at home Shift Emergency to Urgent Redirection / KWTTT Short stay assessment / Avoid admission

16. Staff Perception of Patient Experience Emotional Mapping

17. Developing an Action Effect Diagram: Step one shared aim and contributing factors

18. Overcrowding is a Manifestation of Delay Alternative options 1) Next Day 2) Home Setting 3) Etc. Weekend & Earlier in the day discharges Alternative Model to smooth arrivals? AM PM Evening Over night GP Visit Time SAS “batching” Arrival time at Hospital “Later” Transfers/Discharges later in the day Congestion Crowding in ED Assessment (Admitted / Non-Admitted Evening Staffing Levels Diverts/Boarding/ Direct Admissions Inappropriate late transfers Starting the day with no or “wrong” beds

19. Overcrowding Poorer Outcomes Poorer Patient Experience Increased Delays Greater System Based Variation

20. Hourly ED occupancy and arrival profile, Q3-4 1st Oct to 1st Mar 2015 Average hourly ED occupancy, n, and arrivals at ED, n, by hour of day THIS IS OVERCROWDING

22. Weekly 4 Hr Emergency Access Performance LoS % Compliance by Patient Flow Group Hospital Data

23. AAU spell LoS distribution 1st Dec 2014 to 1st Mar 2015* AAU stays for *all patients who had a LoS on AAU between Dec to Mar 2015, n; AAU spell LoS in 2 hr bins to 72 hr, ≥ 72 hr Notes: (i) AAU spell LoS calculated in minutes Contributes to Front Door Boarding More Complex Older Overcrowding

24. Weekly unadjusted inpatient mortality rate (within 7 days of discharge) 1st Apr 2012 to 1st Mar 2015 Weekly proportion of inpatient discharges resulting in death in hospital or within 7 days of leaving hospital, %; average daily inpatient discharges*, n Notes: (i) *excludes admissions without overnight stays; (ii) XmR-based process control charts recalculated on Wheeler rules 4 and 12-pt baseline

25. Weekly emergency readmissions within 28 days, 1 Apr 2012 to 1 Mar 2015 Weekly proportion of inpatient discharges readmitted as an emergency within 28 days of leaving hospital, %; average daily inpatient discharges*, n Notes: XmR-based process control limits recalculated against Wheeler rules 4 and 12 pt-baseline

26. Day of Care Survey Top 3 Reasons Within Hospital Control (41%- 72%) Awaiting consultant decision/review Waiting for allied health professional assessment/treatment Awaiting procedure/investigation/results Outwith Hospital Control (28% - 59%) Awaiting community hospital bed Home care support availability/funding Awaiting social work allocation/assessment/completion of assessment

28. 6 Essential Actions to Improving Unscheduled Care Learning Workshop 14 day Improvement Challenge Safe, person centred, effective care delivered to every patient, every time without unnecessary waits, delays and duplication Hospital Capacity and Patient Flow Realignment Medical and Surgical Processes arranged to Pull Patients from ED 7 day services Ensuring Patients are cared for in their own homes Clinically Focused and Empowered Hospital Management Patient and Staff Experience Patient rather than Bed Management - Operational Performance 28 To achieve: Improve:By managing: Key themes returned: Escalation Daily huddles Criteria Led Discharge Expected impact: MEDIUM 5 high 6 medium 3 low Analysis/Data/Building Blocks Workforce planning/development HIGH 6 High 5 medium 9 low Hospital at Home Criteria Led Discharge Pre-noon Discharge Ambulatory Emergency Care MEDIUM 5 high 12 medium 3 low LOW 5 high 7 medium 12 low MEDIUM 2 high 11 medium 7 low MEDIUM 3 high 9 medium 8 low Development of pathways Analysis of waits for specialist Review of decision making Increase weekend discharges Reducing surgical variation Review OOH provision Review of decision making Increase ‘at home’ care Preventing admission Frailty model at front door Rapid Access Clinics

29. Discussion Point Of those of you having Quality Huddles or Patient Flow meetings what is the main purpose of them?

30. 6 Essential Actions to Improving Unscheduled Care Unscheduled Care Workshop / learning event Date: 17 th July Time: 10 am – 4pm Where: Stirling Management Centre How Locally : contact your Local Unscheduled Care Team Nationally: unscheduledcareteam@scotland.gsi.gov.ukunscheduledcareteam@scotland.gsi.gov.uk http://www.gov.scot/Topics/Health/Quality-Improvement- Performance/UnscheduledCare