edge talks november 2016: fixing patient flow transcript

SPEAKER:

I am hoping you will be able to use the chat room to tell us what you think about the area, and also,

use #EdgeTalks on twitter to let us know about what you think about flow.

I am your host for today, and Dominic will be supporting in the chat room. Please use the chat box to

contribute, and also tweet using the hash tag, #EdgeTalks.

This is me, Janet Wildman, and Dom Cushnan here.

We have been working with Sasha since June this year and he's a fantastic guy to work with. I have

worked closely with him on a number of projects, and he has been a member of the Nuffield Trust, and

has had a recent publication, "Understanding patient flow in hospitals." I am looking forward to hearing

more about that.

He has held a number of senior positions and will tell us more about tackling the complex issue that

we are faced with today around patient flow. So, we will be looking at the recent Nuffield Trust report,

looking at decision-making and complex environment, and what to do when data doesn't fit.

So, I will hand over to Sasha and take it from there.

SPEAKER:

Good morning, everybody. It is a pleasure to be here talking about this topic.

I found this first picture from a jigsaw. I think this is good in understanding flow, and I will take some

time in understanding why. If looking for Christmas presents, this is a great place to start.

I have been involved with flow for a long time and have been trying to understand the challenges. I

have been working with colleagues to stand back and have a look, and I want to talk through that

experience, hoping that I trigger some useful ideas.

So, understanding patient flow in hospitals is what this is about, and I want to highlight a couple of

pieces that are likely to be published soon, in particular the health foundation and what they are doing.

I will look a bit at whole systems, but most of today's talk is about the in-hospital part. This is where the

major constraint is.

I want to start here, and one of the first things I did when I started with the Nuffield Trust was look at

the four hour standard. In 2014/15, the top 12 trusts breached 4.2% of the type, so they were

achieving just over 95%, and those furthest from this type had a breach rate of almost 18%.

The differences are quite interesting. Those trusts that are furthest from the target are almost twice as

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big as those hitting it, and length of stay was only 0.3 hours. It probably only boils down to that, and

solving that solved the problem of flow.

So, we looked wider at what was happening in the system, and you can see some interesting

differences. Those achieving the target by using more beds per person as opposed to those who

aren't, and they have a higher admission rate which is slightly counterintuitive, and more space

available at midnight.

This got us thinking about those differences and what we could learn from them. So, we will tell you a

bit more about that.

So, one of the big challenges when in your individual hospital at any point in the system is trying to

understand the perspective, and I thought I would illustrate this with a picture. This is part of a mosaic

tapestry, and I'm sure none of you can work out what the picture is, but if you stand back a little bit,

you can see who that is. It is actually Desmond Tutu.

I think this illustrates the problem of needing to bring together information and ideas from lots and lots

of different parts of the system, and to do that in a very nonhierarchical way. Bits of information are not

more important than other parts of the story. What is critical is to build a whole picture of what is

happening to inform what action can be taken, and I feel that very strongly, and we will talk about that

more as we go along.

What I want to say about the data is that most of it has originated from stories, so I firmly believe in the

management by walking about, trying to improve flow in hospitals by talking to people at lots of

different points in the system to understand their perspective. That is tremendously powerful, and then

starting to add numbers to inform those stories, bringing the different parts together. I hope that gives

a rich picture, and we will talk more about that as we go on.

The work we have done in the Nuffield trust links together with other pieces of work that were recently

published. This paper was brought to my attention recently, and instantly, you can start to see that

there are lots of ingredients to get right.

I will start off by looking at this for today's talk, taking those things out of order. I will talk about

population, capacity and process.

Firstly, the population is changing. This chart just shows the likelihood of spending time in hospital,

and it's no surprise that the older we get, the longer we spent in hospital. It is quite profound. Most of

us involved in this call today are probably likely to be spending no more than half a day on average in

hospital per year, yet by the time you reach 85, the average is just under a week per person per year.

Over the last six years, there have been small improvements, so people are spending slightly less time

in hospital, but when you look at this chart in relation to future population change, you can start to see

a potential problem.



This chart shows that. What this shows is that, on the left-hand side, the number of beds that are used

across the country in relation to age, so eventually, there are about 10,000 beds for people up to about

14, ranging up to just over 100,000 for the total population.

By 2020, there is an increase, and by 2030, a bigger increase, leading us to about 140,000 beds if we

continue working where we are today.

That is a big change, and the question is, can we optimise our current systems to deal with that

increase, or do we have to change the fundamental models we are operating with? We will discuss

that as we go on.

Someone has put in the chat box, this is largely a result of the post-war baby boom. By 2030, that

group are increasing massively, and that will have a big impact on what we do.

This underlies one of the key problems that are facing us at the moment, so people were routinely

hitting the four hour standard in 2011, by 2014, they weren't.

That use has been increasing and the number of beds available has been pretty flat. I think that

creates a constraint, with more people trying to fit through a narrow gap, and we will talk more about

that in just a moment.

What is interesting is that that use is partly driven by population, and as the system gets more

ingested, it takes longer to be treated, which is a double whammy.

The classic question, which line would you like to change and which line can you change? We can say

that we would like more beds, but is that possible? We have to train staff to work and operate all of

those beds, which is also not that easy to achieve.

In reality, we need to think much more about how we use the capacity that we have got.

I want to use a picture to illustrate this, and we will all be very familiar with this picture. It tells us a lot

about the problems that we are facing in hospitals. Firstly, that the design of the motorways has been

remarkably stable for a long time, and typically they have three lanes. You can see a recent innovation

of a managed motorway where we have bought the hard shoulder into use. It is tempting to say it is

the extra cars that are causing the problem, and it is tempting to say it is the lorries that our problem.

In reality, it is the interaction of all of the traffic in a particular situation.

We need to think about that.

I then thought I would illustrate some of the concepts of flow, putting a few numbers to this picture.

Those who have read the report will have seen these numbers before.

The left-hand lane is travelling slower than the right-hand lane, and there is variation across the lanes.

The fastest driver complying with a 70 mile an hour limit should take about 28 seconds to cover a



kilometre.

This goes up from taking 28 seconds to cover a km to 37 seconds. As you get up to heavy congestion,

you can see the number of vehicles in a kilometre obviously increases massively as does the journey

time. This is really illustrative of some of the problems. If you imagine a congested emergency

department and think through the amount of time it takes to care for the patients in a free-flowing

situation, it might be around 28 minutes, and in this illustration, it is nearly 7 times more by the time

you get a heavily congested situation, so the workload in a constrained area massively increases. As

we all know, it is massively more stressful driving in those situations, so we have to think also about

what kind of environment we are creating for people to work in, and more importantly, to be cared for.

Let's try and apply that to a problem we are dealing with daily.

I want to talk about it in these terms. How do we better measure and manage flow? What can we do to

transform the way we look after people, and to what extent can we avoid the need for people to travel

through the system?

Starting off with a chart of occupancy across the country. It is relatively complex. You can see, we can

week, the pattern of activity is pretty similar. You can see that over the summer the level of activity

drops. You can see a massive fall on Christmas Eve when virtually nobody is left in hospital, and you

can see the winter period over to the right just after Christmas.

The red line in the middle of the chart with a couple of little steps in it is the number of beds recorded

as available across the country.

The dashed line right at the top of the chart is the number of beds you would have required in 2014/15

if you decided to apply the 85% rule. You can see at that level, there would be enough beds for all

sorts of situations. You can also see a huge number of white space above the number of beds we

actually use, which suggests we would have a huge amount of spare capacity for much of the year, if

we use that rule. There is a judgement between the number of beds being used and the old, if you like,

rule of 85% – where do you draw that line?

The other important point is, should we be planning to merely cope, or should we be planning to

maintain a consistent level of service? In many other walks of life, we as consumers expect to get the

same standard of service pretty much whatever we want to consume it, and why should hospitals and

healthcare be different? We need to be building insufficient resilience to cope not just today, but next

month and next year to make sure the quality of the experience is high.

The other point to note – this is really important – we used to measure and still measure hospital

occupancy at midnight. In the old days when matron went round admit night and checked everybody

was in bed, that probably made sense, but since then, we have massively increased a surgery on the

day of admission surgery, the amount of emergencies and emergency patients spending less than a

night in hospital has increased massively, yet we haven't change the measurement standard. I want to

talk a little bit about that in a moment. But just to say that floor planning, actually plotting the data over



a year, and ideally even longer, will give you useful information. It is an important discipline of being

able to visualise what is happening, as opposed to just seeing data on a spreadsheet.

This chart takes it further and looks at bed occupancy during a day across a couple of month periods

where it is smooth data looking at each day of the week across a two-month period.

You start off with… The zero is the bed occupancy at midnight, what you would normally see if you

look at hospital occupancy. I have calculator this to say an increase in bed occupancy is a negative

thing because we need usually to find more beds, so you can see between midnight, which is zero on

the chart, and eight in the morning, occupancy in most hospitals increases. It is actually worse on a

Friday and Saturday night for not massively surprising reasons.

There is a net reduction in occupancy from 9 AM. By six, seven in the evening, is the lowest point of

occupancy. If you walked into most emergency departments, I think you would be surprised by that

because that is when the biggest queues happen. What is happening? We will come to that.

One of the key points of this chart is to differentiate between the idea of the occupancy, which is

actually not when most of the flows happening, and the notion of peak flow. Peak flow is when the

grass is almost vertical, so lots of people moving each hour, compared to when the graph is almost

horizontally flat when virtually no movement is happening, or net movement, in the hospital. You can

see a big difference between the weekdays and weekends in this particular hospital. In fact, over the

weekends, there is no net improvement in occupancy over the weekend. That is in many cases a

problem.

What happens when the system is not designed to deal with the flow rate? This charter tries to explain

that. What you have is, on the top line, the flow rate per hour, so you can see that at four or 5 AM, just

under 2% of the day's work per hour is happening, compared to 5, 6 o'clock in the evening, when

nearly all of the activities happening. And so just to see what happens, this chart then said, what

happens if we designed this system so that only 5.5% of the day's work and be done in an hour? This

applies particular to things like hotel services potentially, how many doctors you have in the system,

potentially how well resourced your radiology department is, but this chart is not specific.

What you can see is, if there is 5.5% supply and demand any 8%, somewhere around 6 PM, you have

nearly 10% of the day's work waiting. That starts to resolve somewhere around 8 PM, but there is still

4% of work waiting at 11 PM.

We have ended up with a big queue. If you think of the work rate at around 5.5% per hour, you are

adding almost 2 hours to patients' waiting time.

The interesting thing to say about this is it is not just about the beds. You could have beds. You just

cannot get people to them. It is a little bit like the motorway situation when you get stuck in a traffic

jam, and then you find an empty road and you wonder what it is all about. This is the same. There may

be beds at the end of the system, but because we have not matched the internal flow through the

hospital, you cannot get to them. We will talk a little bit about that now.



This is a slightly retarded point, but does your bed change to look like this? I defy anybody to stick into

the chat box that theirs does. There is remarkably little data about what happens during the day, how

long does it take to get a bed ready for the next patient, how long does it take to move a patient. One

of the big challenges we have is that actually the systems we use in small hospitals and big hospitals

are remarkably similar. I quite often like to test whether something appears sensible in one situation, is

sensible when you look at it in a different place. Just imagine the twice-daily landings meetings at

Heathrow airport where at 8 o'clock we have about 500 planes arriving today, and it will be checked

what will happen at 2 PM, and see how it goes.

Where you have a lot of movement, the need for real-time coordination increases substantially, and

the ability to save only a few seconds and a few minutes matters a lot. How do you choreograph the

interaction between teams in the hospital? It is an easy question to ask. It is difficult to do in practice.

These sorts of interactions might be one of the ways we can at least make our existing systems work a

lot better, and should be an awful lot easier to do than just building more beds.

This does not have to be difficult. As I said when I started, lots of the information in this report has

come from talking to people about their experience and trying to piece the individual parts together. A

lesson I learnt a few years ago about how do you run an airline? They all have control centres and the

interesting thing about them is they do not try and build one big computer system, they basically say

the individual types of aircraft must have train crews to fly them. If you're flying 737's, you don't have to

know much about 787's. If you're running a crew in London, you do not have to know about what's

happening in Manchester. You coordinate between them. I think that starting to think about what each

of your individual teams knows and how you can bring that information together in a more structured

and real-time way take you quite a long way forward, but if you can move to real-time data, particularly

where there is a lot of movement, it will help massively. I will explain a little more about that in a

moment.

One of the challenges of why this is important is actually that average length of stay is a varied

measure of planning flow through hospitals. We are now in a situation where 58% of activity is zero

day.

That is clearly a mistake because people have been through and left. It is like measuring traffic over

the Avon Bridge on the M5. If you measure it in the afternoon, it is very different to two o'clock in the

morning.

You have to work out how much the zero day patients are using. In this report, we assume it is 12

hours because there is no national recorded data. It is probably a lot less than that, but one thing that

has changed more is the volume of zero day patients.

Zero day activity increased over six years, and unless you have matched that, it is highly unlikely you

will end up with the same thing.



At the other end of the extreme, only 10% of patients now stay in hospital over seven days. They use

65% of the beds. Going back to the motorway analogy, when I talked about motorway traffic varying,

this is a much greater variation. Those patients typically spend 30 something days, see you are

looking at 50 to 60 fold variation, and that has huge impact on what is happening.

Very easy to think we can go back to where we have come from, and I would caution against that. A

lot of the reasons that have driven as to day surgeries, units, bringing people into hospital to get the

right kind of diagnostic and interpretive skills are not that easily removed.

For example, we created something to speed the process up, but also, to manage the directive. We

introduced day surgery to improve the quality of experience and to free up beds. All of these changes

have been made to improve efficiency and effectiveness of the system, but they come to a point when

they create new constraints, so we need to think about new solutions to problems, and I just think that

we can re-engineer the past.

One key point of this talk is that we need to not look in the rearview mirror. We need to look at novel

solutions that deal with the current problem, but also take account of the problem we will have in the

future because the population is continuing to change. We are taking a medium- to long-term view as

we make decisions.

One of the big challenges is that people say it is all about getting people out into nursing and

residential care, as well as getting the same amount of domiciliary care.

This chart looks at people who were discharged, and there's been a 30% increase and length of stay

has increased. We're not making sufficient progress to keep the system imbalance.

When you compare that that increase to, for example, the space required for the zero day patients, it is

not that far removed, and when you compare it to the likely increase of bed increase, that looks to be

about 6,500 beds over the period that this report is based on.

So, as fast as we are improving, other pressures are moving in the other direction, and that is one of

the problems of our planning mindset. We hope we can improve from where we are, but we don't

always wait sufficiently with the countervailing forces.

So, before I come to solutions, I just wanted to pick up on a few thoughts. This challenge that we are

all dealing with now to improve flow has emerged over a three- or four-year period, and we are only

just starting to get a really good grip on what is going on.

I would argue that our approach to problem-solving has contributed to that. This is a picture of the



constitutional court in South Africa, and for those who have been to Johannesburg and seen this

building, you will know it is a very powerful piece of architecture.

The picture on the right hand side illustrates the atrium, as the big pillars that other men to replicate

palm trees and the African story of, if you have a problem, sitting under a tree to think about it.

Sometimes I can take quite a long time. Actually, sitting and talking, discussing, are really important

parts of problem-solving, but doing it from a qualitative point of you without bringing some data to the

discussion is not a good way of doing things, so balancing storytelling with data is something I would

strongly advocate.

The second part is listening and thinking in a structured way, and this is very illustrative of that. The

windows you can see just behind where the judges are sitting, and those are symbolic. It is there to act

as the public, telling us something important about the transparency of the process, reaching a

consensus as a group.

So, when we have these complex problems, thinking a lot about the decision-making environment and

how to make it as nonhierarchical as possible offers real opportunities for speeding up the decision-

making process.

Just moving onto that and what else is a problem. When Nigel Edwards and I started looking at flow,

one of the key quotes was that the current data doesn't describe the problem. That can mean that the

data is wrong, but also, that the environment is changing. So, I think we have to use all of our senses

to solve a problem like this, checking that the data is telling you what you think, but if it isn't, it is not

time to sit back. It is time to think about how we can get new data.

Intuition is important, and one of the key messages from this piece of work is that lots of individuals

had key parts of the jigsaw but not the whole picture. The challenge of leadership is to build that whole

picture in a way that gets appropriate action to happen.

What the story does tell us is that the environment is changing. Over the last few years, death rate has

been declining in the country, and it's now predicted to increase over a very long period. A lot of the

past expectations of continual improvement need to change, and when you get those inflections in

data, it is usually sign of the significant environmental shift, which means that planning assumptions

looking backwards won't help very much.

This takes us to the latest news. We contributed to this work, but yesterday, the House of Commons

health committee issued its latest report on winter pressures, and one of their conclusions is really

important, that the response is to focus both on managing the patient's journey through the hospital

and in addressing the increasingly inadequate provision of adult social care services available to



enable safe discharge.

I think the key here is that we need to be doing both, so most likely, the best strategies, I think, are to

improve data collection as part of workflow. We are also thinking about longstay patients, and if you

could halve the amount that people were spending in hospital, you would release about 30% of the

current bed stock. This would move us from having a bed problem and a flow problem to organising

out-of-hospital care.

So, as we move to solutions, think how to speed up the journey. Think of what is required. One size

will not fit all for people, so it needs a differentiated and thoughtfully put together approach.

So, in conclusion, the environment is changing rapidly, and we all know that we can't tackle it the way

we are at the moment, and that we need to find different ways of managing flow, thinking through the

needs of different segments of patients in the system.

I will leave you with this picture. That's what comes out of that jigsaw that I started. I think it is time to

remove the blockages, and for those of you who are interested in the theory of constraints, that is

absolutely vital.

I will leave some time for discussion, and I hope that has been helpful to you.

Janet, do you want to… Come in and see if there are any questions?

JANET:

Thank you. That was fascinating. There has been a lot of activity in the chat room. I wondered if I can

go over to Don to get a summary of the things that have come up there and on Twitter.

SPEAKER:

Apologies. It looks like we're having some interesting conversations. One of the questions that has

come up is what is driving the zero day patient trend? There is a separate conversation around real-

time tracking.

SPEAKER:

I think what is driving the trend is multifactorial. It is not completely clear. I think it is coming from two

directions – one is were getting better at solving problems faster, so some of the growth is by stopping

the need for one or two day stay in hospital because we are much slicker at it. Some of the need is this

increase in complexity, and in GPs on doing a fantastic job of intuitively managing people with

increasingly complex needs, but the size of the population with three, four, five long-term conditions is

growing enormously, and you get to a point where you need access to specialist diagnostics, and you



need that in a coordinated way, which at this point in time is difficult to do outside a hospital setting. So

I would say those are the two key nonelected pressures. On the elective side, again, more and more

day surgery is happening, so all of those things are good, but it requires a different standard of flow

management, and the move towards real-time data to do it slickly, I think.

In terms of data collection, I think it is really, really important. A few years ago I met a chap who was

the research director at Microsoft, and he was actually a doctor by training. We asked him, "Have you

any tools to manage flow-through hospitals?" He said he would love to solve the problem. It was so

difficult. It was easier to map traffic flows around Seattle. At least the staff could get home in time and

think about it. Over the last about five years I've heard that story. Over those five years, the ability to

get data really cheaply has changed exponentially, so very few hospitals now don't have Wi-Fi. We

have a whole raft of tracking devices, we have new sets of tools around visualising data, and I think

there is a role for many of these, but it is really, really important to think about the workflow and

experience we have designed both for the patients and for the staff. If we simply add this into a chaotic

system without thinking about how to simplify, I think will end up in a bad place.

Just to illustrate that, asked the designer to have a look at some of the patient flows for complex

patients and one of the hospitals I worked in. He said, do you know how questions are asking

patients? The answer is 1400. Some were duplicates. We had invented 28 different forms for the staff

to fill in. You can't think that process will be very quick and all of those questions will be that relevant to

the safe delivery or the efficient delivery of care, so I think we need real-time data, but we really need

to think through how to present that to people in a way that is useful to them.

SPEAKER:

Interesting. "Is a motorway more like the flow of under 65 patients rather than the patient's use in

hospital today?

SPEAKER: It is a very good question. I think the interesting thing about traffic is it represents

everybody, and I think the flow through a general hospital represents everybody, so you will get some

people on a motorway travelling one junction, you will get some people who you would not want to be

driving next to, because they aren't quite as aware and responsive as others. The same applies to

hospitals. We have a pastoral people moving very quickly, but we have some slow ones. I think it is a

reasonable and allergy. I think the important point, though, it is not just about the people using the

service, it is about the interaction between them, so if you think about your own car, it is perfectly

capable of travelling at least the speed limit, but if you're stuck in congestion, you will not be able to

use that potential, so actually it is the interaction between patients that matters as much as the specific

types of patients in a flow situation.



SPEAKER:

Thank you, Sasha. One comment – Melly says if staff and patients think beds would be a solution, but

we can do for them, it would be a massive barrier. But it is more about safety. We must value our

patients' time and we need to deliver this message in a strong way, and we cannot afford beds.

SASHA:

I think that is a really good point. I know that if I suffer a poor experience, it makes feel angry and

unhappy in a hospital situation. I think that notion of valuing firstly the patients' time, but also valuing

colleagues 'time might well help us handle the resource constraint.

SPEAKER:

That is really helpful. We are slightly early, but I found that hesitation fascinating. What do you project

for the next couple of years going forward in terms of flow? Do you think we have the right technology,

right know-how, right approach to how we manage data to move this to another place so we will not be

having the same conversations in a couple more years?

SASHA:

That is a challenging question. I think we really difficult. The challenges are real. We will have to run

faster to stand still. That said, there are significant numbers of really innovative players in the tech

sector who have interesting ideas and approaches that could make a big difference. I'm aware of really

interesting innovation in out-of-hospital care that is starting to make a big difference. Those sorts of

innovations, the harder we do rehabilitation, how do we systematically enable people to connect to

voluntary help in their communities and so on? I think, for those who are entrepreneurial, those who

really want to make a difference, the next two years could be really exciting. The biggest danger is

saying it cannot be done, or trying to be too cautious. I think we need big energy, and to use the best

skills that exist within the health service, also the best skills that exist without it.

SPEAKER:

In terms of having three main points you would make to NHS England and maybe MPs today, what

with the three main points be following some key issues you mentioned?

SASHA:

In terms of your last point, I think we have to aim of the problem as a system. We have to be precise

about the request to MPs and people outside the system. This is largely a technical problem, but we

have to have a very clear ask, how would we like customers to respond? What help do we need from

wider society? I don't think we should ask a panic to a general question.



My key message regarding problems is this is not a time for people to be acting in a hierarchical

judgement away, it is time to be acting to be bringing the knowledge they have to the table and to

make sure we use all of the parts of the jigsaw, not just a few of them, because it is a very complex

situation, it is a fast moving situation, and that implies the need for very active teamwork, so my

metaphor for that is the Apollo 13 film, for people who have seen it. We need that kind of urgency and

collaboration to really drive innovation.

SPEAKER:

I wanted to go back to your role within Horizons. How do you think the team and what we do could not

necessarily resolve the issues, but bring it up to the priority list for NHS England to address?

SASHA:

in a number of ways. One of the really interesting things is there are lot of people close to the front

line, involved in the school for healthcare radicals who have fantastic ideas, and we can help, I think, in

convening those ideas and helping people to test them and put them into action as quickly as possible.

The other thing we can do is to share our knowledge of innovation happening in the world. Early in the

week I was talking to some European colleagues. They were judging a connective health award. We

had ideas from all of these sorts of themes I talked about earlier on today, so we don't just have to look

within the country, there are some interesting ideas emerging right across Europe and around the

world, so I think we can share some of those ideas and hopefully get them into action faster.

SPEAKER:

Fantastic. That is it for now. Do you have any last minute thoughts you need to share? I think you've

taken us through quite a journey today, and a lot for us to think and reflect icon. We have a couple

more minutes. Is there anything to end with?

SASHA:

I don't think so. I hope that has been really useful. I am happy to respond to questions or thoughts that

people have after the event, and if there is anything we can do to help, we are open to having a

conversation about that, so I hope that has been useful, and it has been a pleasure to put together.

SPEAKER:

I think everyone in the chat room would like to say thank you. It has been helpful, useful and lots of

positive comments coming through. We appreciate you sharing all of your expertise with us today. We

are going to be talking about the next Edge Talk coming up shortly. Empowering people to be heard

and helping leaders to listen. We look forward to seeing this and hearing about this fascinating subject.

We afford you coming on the next Edge talk session. We hope you have a fantastic weekend. Thank

you for contributing and supporting the session today. Thank you to everybody. Goodbye and have a

good weekend. Bye.



SASHA:

Bye.



edge talks november 2016: fixing patient flow transcript

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