is it really possible to improve quality and reduce cost in the nhs? · 2015. 4. 21. · stroke...

Is it really possible to improve quality and reduce cost in the NHS?

Dr Steven Allder

[email protected]

My background

Clinical Junior Doctor, MRCP, Research

Consultant Neurologist

Improvement/Management/Leadership development

RCP/III, OSPREY, Safer Clinical Systems

NHS Executive Fast Track Scheme

Roles

Service lead, CD Neuroscience and Ophthalmology, Head of Service Improvement

AMD, Board member Glos CCG

Iterative learning journey

1 2 3 4

2001-2015

Too much demand

Not enough hope

Very depressing

EmpiricalStories

Technical Evidence - CSI

Behavioural Evidence - EI

The NHS Challenge!

Financial reality

My answer to the question?

Yes, definitely…however…two buts

A small but, and

A very big BUT

Yes, Definitely 1:

Beds Per Day Occupied by Neurology Patients (excluding Patients with Main Diagnosis of Stroke)

10

15

20

25

30

35

40

45

50

31/0

3/0

514/0

4/0

528/0

4/0

512/0

5/0

526/0

5/0

509/0

6/0

523/0

6/0

507/0

7/0

521/0

7/0

504/0

8/0

518/0

8/0

501/0

9/0

515/0

9/0

529/0

9/0

513/1

0/0

527/1

0/0

510/1

1/0

524/1

1/0

508/1

2/0

522/1

2/0

505/0

1/0

619/0

1/0

602/0

2/0

616/0

2/0

602/0

3/0

616/0

3/0

630/0

3/0

613/0

4/0

627/0

4/0

611/0

5/0

625/0

5/0

608/0

6/0

622/0

6/0

606/0

7/0

620/0

7/0

603/0

8/0

617/0

8/0

631/0

8/0

614/0

9/0

628/0

9/0

612/1

0/0

626/1

0/0

609/1

1/0

623/1

1/0

607/1

2/0

621/1

2/0

604/0

1/0

718/0

1/0

701/0

2/0

715/0

2/0

701/0

3/0

715/0

3/0

729/0

3/0

7

Be

ds

Oc

cu

pie

d a

t M

idn

igh

t

No. in bed

Mean

UCL

LCL

Yes, Definitely 2:

Planned Care Unscheduled Care Total

New FU IP DC IP

Speciality A Q V A Q V A Q V A Q V A Q V A V

I II III Total I II III Total

AE A&E - - - - - - - - -

AM Acute Medicine ? ? -

AS Anaesthetics ? ? ? ? ? - -

AU Audiological Medicine - - - - - - - - - - - - - -

BS Breast Surgery - -

CS Cardiac Surgery

CD Cardiology

CM Child Psychology - - - - - - - - - - - - - -

AN Chronic Pain -

CC Clin Chemistry ? ? - - - - - - - - - - - - - -

HM Clin Haematology

CI Clin Immunology - - -

RT Clinical Oncology

CO Colorectal Surgery

CP Community Paediatrics - - - - - - - - - - - - - -

DM Dermatology - -

DI Diabetic Medicine - ?

EN Endocrinology - - - - - - -

ED Endoscopy -

ET ENT

GA Gastroenterology

GM General Medicine - - - - - - - -

GS General Surgery

GU GUM ? ? - - - - - - - - - - - - - -

GC Gynae - Colposcopy Suite - - - - - - - - - - - - - -

GH Gynae - Hysteroscopy - - - - - - - - - - - - - -

GO Gynaecological Oncology

GY Gynaecology

HF Haemophilia ? ? - - - - - - - - - - - - -

HE HCE

PS Hepatobiliary & Pancreatic Surgery ? ? - - - - - -

HP Hepatology

IC Intensive Care - - - - - - - - - - - - -

MO Medical Oncology

NE Neonatology - -

NF Nephrology

NL Neurology

NY Neuropathology - - - - ? ? ? ? ? ? - - - - - ?

NP Neurophysiology - -

NX Neuropsychology - - - - - - - - - - - - - -

NR Neuroradiology - - - - ? - ? - -

NS Neurosurgery

NM Nuclear Medicine ? ? - - - - - - - - - - - - - -

OB Obstetrics - - - - - - - - -

OP Ophthalmology - - - -

ON Optician - - - - - - - - - - - - - -

OS Oral Surgery

OD Orthodontics ? ? ? ? ? - - - - -

OR Orthopaedics - - - - -

OT Orthoptist ? - - - - - - - - - - - - -

PA PAC - - - - - -

DP Paediatric Diabetic Medicine ? ? - - - - - - - - - - - - - - ?

PD Paediatrics

PT Palliative Medicine - - - - - - - -

PL Plastic Surgery

RA Radiology ? ? ? - - ? - -

RD Rest Dent - - - - - - -

RH Rheumatology -

TM Thoracic Medicine

TS Thoracic Surgery

TI TIA ? ? - - - - - - - - - - - - - -

TR Trauma - - - - - - - - -

UG Upper GI Surgery

GE Uro-Gynaecology - - - -

UI Uro-Infertility - - - - -

UR Urology

VS Vascular Surgery

Yes, Definitely 3:

1. Understand the work different Service Lines do: A value stream analysis at Trust level

2. Align quality and financial standards developed by programmes to flows

3. Prioritise

Key Areas

-Longer stay unscheduled care patients40% of beds are occupied by patients who have stayed more than 7 days –this equates to approximately 300 beds

-Significant capacity and demand problem across each step of the scheduled care pathwayCapacity and demand mismatch

Yes, Definitely 4:

Making sense of ‘the buts’:The Complete Coherence Leadership Model

Personal PerformanceStep change quality of thinkingDevelop boundless energyUncover personal purpose

People LeadershipIdentify organisational “Way” & evolve organisational culture

Develop executive fellowships & high performing teamsClarify personal leadership qualities

Operational performance todayFinanceED PerformanceWaiting timesSafety

Operation Performance tomorrowClarify vision Set ambition

Uncover purposeIdentify strategic building blocks

Develop full growth portfolioDecide on customer battlegrounds

Establish effective governance

This involves change, really involves creation which is hard









Need to create…

Why, How, What..

First part of How: What to do I need to do differently?









Need to create…

How?

Two interrelated HOW challenges…

Small but..









Need to create…How 1:

Systems approach

A very big but…









Need to change…How 2:

Socio-cultural

The small but:How to find opportunity to improve care and reduce cost

Technical Analysis

Principles

Operational thinking – 3rd generation systems thinking

This is consistent with emerging reviews of NHS policy

A Compelling How?

The experience of high-performing health care organisations shows the value ofleadership continuity, organisational stability, a clear vision and goals for improvement,and the use of an explicit improvement methodology.

Systems Approach: Vanguard method building on best of health care improvement science

In health care – there are lots of potential symptoms

One department’s data from Trust Databook

Current approach = tackleas issues arise in isolation

Proposed approach =‘systems – value’approach to issues

YOU CAN START ANYWHERE!1. How to find opportunity in theory2. How to deliver results locally3. How to deliver results more broadly

Starting point is ALWAYS multiple symptoms

Need a value framework to orientate you

Putting it all together:Stroke example

Technical Analysis

2008 - Worst Performer in Region

95

76

76

79

91

93

96

96

99

University Hospitals Bristol

Poole

Taunton And Somerset

North Bristol

Royal Devon And Exeter Healthcare

Northern Devon Healthcare

Plymouth Hospitals 118

105

Salisbury Health Care 107

Yeovil District 111

Royal United Hospital Bath 112

Royal Bournemouth and Christchurch 116

Dorset County Hospital 117

South Devon Health Care

Weston Area Health

Royal Cornwall Hospitals

Cheltenham General Hospital 102

Gloucestershire Royal Hospital 102

Great Western Hospitals

Stroke in-hospital deaths by NHS hospital4

Standardised mortality rate (percent of national average)

In 2008/ 2009, PHT death rate was 18.3%higher than the national average

£2,000 Loss per Patient1.5 patients per day average£1.1 million annual loss

Poor Patient & Relative Experience

Step 1 – Move from cost control to value creation

Choose demand stream to start with

£

Challenge

Value of clinical work

Activity £

C C

Activity

Support Support

SS

SS

C C

Starting pointClinical Clinical

Value framework (1)

This is very differentand very challenging

Step 2 - Define Sub System

Key provide pathways involved

Regulators

System Architect (commissioners)

PrimaryPrevention

PrimaryCare

SecondaryUSC

SecondarySC

CommunityCare

1

2

3

MH

SC

EG

Te

Tr

RFrontline Individuals

Model of Healthcare System

PurposeAdd valueConditionLevel

PATIENTS

Frontline Teams

Frontline Management

Middle Management

Senior Management

Direct value

creation

Indirect value

creation

Step 3: Define ‘entry’ patient demand stream

Population segmentation exercise

Programme Budgeting

PrimaryPrevention

PrimaryCare

SecondaryUSC

SecondarySC

CommunityCare

1

2

3

MH

SC

EG

Te

Tr

R

Model of Healthcare System: Demand streams

0

1

2

3

4

5

6

7

8

1-A

pr-

06

1-M

ay-0

6

1-J

un

-06

1-J

ul-

06

1-A

ug

-06

1-S

ep

-06

1-O

ct-

06

1-N

ov-0

6

1-D

ec

-06

1-J

an

-07

1-F

eb

-07

1-M

ar-

07

1-A

pr-

07

1-M

ay-0

7

1-J

un

-07

1-J

ul-

07

1-A

ug

-07

1-S

ep

-07

1-O

ct-

07

1-N

ov-0

7

1-D

ec

-07

1-J

an

-08

1-F

eb

-08

MeanNumber of

admissions

Mean has been 1.5

admissions per day

over the past two years

UCL*

Inpatient demand stream

Stroke Patients Admitted per Day

Step 4: Define key consumption stream

Understand authentic cause of variation in performance:

1. Demand sub-type

2. Stage of care

3. Step of care

3

2

High (8+)

Med (3-7)

Low (<3)

2009

499 (84)

83 (14)18 (3)

ALOSDays

Number of bed days (percent)

MeanLOS

0

20

40

60

80

0 50 100 150 200

ALOSDays

Consecutive patients

Length of stay for patients with ALOS ≥8 days

Quality:Interactionof streams

Identify Hot Spots of resource consumption(Ideally, quality then cost)

PrimaryPrevention

PrimaryCare

SecondaryUSC

SecondarySC

CommunityCare

1

2

3

MH

SC

EG

Te

Tr

R

Model of Healthcare System: Consumption streams

Step 5: Dissect consumption stream

Understand authentic cause of variation in performance:

1. Homogeneous demand sub-type

2. Stage of care driving variation

3. Step of care driving variation

3

5

Quality Grid guided case note review:Emergent element of process

Presenting complaint/D

iagnostic sub -division

* Rehabilitation Stroke Unit** Frail patients were defined as having medical complexity index of 3, 4, or 5 on a 1-5 scale. 0=No systemic disease other than primary diagnosis , 1=Premorbid, inactive, and or

irrelevant systemic disease, 2=Active, relevant systemic disease not limiting function, 3=Active, systemic disease limiting function, 4=Active, systemic disease severely limiting function, 5=Moribund / terminal intermediate

Home(23%)

RSU(13%)

RSU(11%)

RSU orconvalescence(20%)

RSU* orconvalescence(17%)

Well (47%)

Frail**(53%)

Mild Moderate Severe

Clinical stroke size

Patientstatus pre-

stroke

Preferred place of discharge for 6 subgroups of patients3 (percent of total)

Pathway redesign required (16%)

5a. Which Demand sub type (s):

Six types of patients were defined based on patient status pre-stroke and the size of the stroke

Pathway redesignrequired(16%)

Home(23%)

RSU(13%)

RSU(11%)

RSU orconval-escence(20%)


Well (47%)

Frail(53%)



Patientstatus pre-stroke

Step 5b: Which Stage of care

Target Group 1 –Redesign Pathway:

Discharge

Target Group 2 –Improve Operational

Rigour:Rehab

Pathway redesignrequired(16%)

Home(23%)

RSU(13%)

RSU(11%)



Well (47%)

Frail(53%)



Patientstatus pre-stroke

Step 5c: Which Step of care

Target Group 1 –Redesign Pathway:

Whole process

Target Group 2 –Improve Operational

Rigour:ASU-RSU

Step 6: Redesign steps

The pathway was then redesigned for the keysegment (frail patients with severe stroke), andoperational improvements were initiated in theRSU for four other patient segments

Structuring thinking about designing the specific step care: frail

1.Frail Elderly

RIP

2.Morning handover

4.Expectant pathway 3.Very

intimate

5.Protocol

7.Team

6.LCPHospice

8. Costs far less

Severe Stroke in Frail Patients

Highest resource consumption

75% of beds were used by the frail patients pre-stroke

Highest variability in bed occupancy & long length of stay

Driven by a lack of systematic care planning

Care not well-matched to patients

Variable treatment and feeding processes, not aligned with patient and relative preferences

RSU Operational Rigour (1)

No frail patients with severe strokes are sent to RSU

Active decision for frail patients with moderate stroke

Based on clear triage rules and input from acute care providers, relatives and patients

Previously well patients with moderate or severe strokes go to the RSU

Rigorous monitoring is used to determine when patients can be sent home with enhanced community resources (early supportive discharge) or to long-term placement (e.g., nursing home)

RSU Operational Rigour (2)

Rigorous daily review

Status of all patients is reviewed daily (discharge round)

Staffing adjustment to reduce ALOS

A dedicated social worker was added to the RSU to help reduce ALOS

Consider ongoing re-design

PHT is currently redesigning its RSU pathway, assessing its options for community services, and reassessing its pathway for frail patients with mild strokes

In under a year, access to and use of the Acute Stroke Unit has

become more efficient3

0

0.5

1.0

1.5

2.0

2.5

-12% p.a.

FebJanDecNovOctSepAugJulJunMayApr

0

5

10

15 -6% p.a.

FebJanDecNovOctSepAugJulJunMayApr

0

10

20

30

40

50

60

70

80

90

100

+7% p.a.

JunMayAprMarFebJanDecNovOctSepAugJulJunMayAprMar

2009 2010

Percentage of patients spending at least 90% of their time in the

ASU*,3

Percentage

2009 2010

Time required for transfer to ASU3

Hours

2009 2010

Average LOS in ASU3

Days

* This is one of the major indicators in the UK National Stroke Audit; if patients are not spending time in the stroke unit, they are either in the A&E or the

medical assessment unit, likely not getting the most appropriate care

20

33

June 2009April 2009

Acute beds at Derriford Hospital

Rehab beds at Mount Gould

19

23

May 2009April 2009

Net acute benefits

•Reimbursement level: £4k per patient

•New cost of care: £3k per patient, Savings: £1k

•17 beds released, implying net savings of 11% across system

Lots of Beds Saved…Permanently

An offer of hope

is it really possible to improve quality and reduce cost in the nhs? · 2015. 4. 21. · stroke...

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