nhsscotland event 2015 leading integration for quality a:2 unscheduled care – can we fix it?
TRANSCRIPT
NHSScotland Event 2015 LEADING INTEGRATION FOR QUALITY
A:2 Unscheduled Care – Can We Fix It?
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
Unscheduled Care…. Can we fix it?
6 Essential Actions to Improving Unscheduled Care
The overall aim is to : •Improve Patient Care•Improve Patient Experience•Improve Patient Outcomes
Long term trend in A&E performance
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
Attendance and admissions by age
https://isdscotland.scot.nhs.uk/Health-Topics/Emergency-Care/Publications/2014-11-25/Attendances_Nov14.xlsx
Daily hospital inpatient arrival and discharge profile, Anytown Hospital 1st Dec 2013 to 1st Mar 2014
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!
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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
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
Discussion point
Who are the people in charge of your hospital after 9pm?
•Who makes decisions•On site •Off site
The Six Essential Actions To Improving Unscheduled Care
A way forward
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 EscalationSafety, Flow Huddles
Basic Building BlocksBed Planning ToolkitWorkforce Capacity ToolkitGuided Patient Flow Analysis
Patient tracking through System Admission/ discharge predictionBalance capacity & demandProactive Discharge Management
Triage to appropriate assessmentFlow through EDAccess to Senior Decision MakerAccess to Assessment/Diagnostics
Smooth admission/ discharge profileSurgical Emergency & Elective Services Integrated SAS Services/ decision support GP/OOH services
Living & dying well at homeShift Emergency to UrgentRedirection / KWTTTShort stay assessment / Avoid admission
Staff Perception of Patient ExperienceEmotional Mapping
Developing an Action Effect Diagram: Step one shared aim and contributing factors
Overcrowding is a Manifestation of Delay
Alternative options
1) Next Day2) Home Setting
3) Etc.
Weekend & Earlier in the day discharges
Alternative Model to smooth arrivals?
AM
PM
Evening
Overnight
GP Visit Time
SAS “batching”
Arrival time at Hospital
“Later”
Transfers/Discharges later in the day
Congestion Crowding in
EDAssessment (Admitted /
Non-Admitted
Evening Staffing Levels
Diverts/Boarding/Direct
Admissions
Inappropriate late transfers
Starting the day with no or “wrong”
beds
Overcrowding
Poorer Outcomes
Poorer Patient Experience
Increased Delays
Greater System Based Variation
Hourly ED occupancy and arrival profile, Q3-4 1st Oct to 1st Mar 2015Average hourly ED occupancy, n, and arrivals at ED, n, by hour of day
THIS IS OVERCROWDING
Weekly 4 Hr Emergency Access Performance LoS % Compliance by Patient Flow Group
Hospital Data
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
Weekly unadjusted inpatient mortality rate (within 7 days of discharge) 1st Apr 2012 to 1st Mar 2015Weekly 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
Weekly emergency readmissions within 28 days, 1 Apr 2012 to 1 Mar 2015Weekly 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
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
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
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To achieve: Improve: By managing: Key themes returned:
EscalationDaily huddlesCriteria Led Discharge
Expected impact:
MEDIUM5 high
6 medium3 low
Analysis/Data/Building BlocksWorkforce planning/development
HIGH6 High
5 medium9 low
Hospital at HomeCriteria Led DischargePre-noon DischargeAmbulatory Emergency Care
MEDIUM 5 high
12 medium3 low
LOW5 high
7 medium12 low
MEDIUM2 high
11 medium7 low
MEDIUM3 high
9 medium8 low
Development of pathwaysAnalysis of waits for specialistReview of decision making
Increase weekend dischargesReducing surgical variationReview OOH provisionReview of decision making
Increase ‘at home’ carePreventing admissionFrailty model at front doorRapid Access Clinics
Discussion Point
Of those of you having Quality Huddles or Patient Flow meetings
• what is the main purpose of
them?
6 Essential Actions to Improving Unscheduled Care Unscheduled Care Workshop / learning event Date: 17th July Time: 10 am – 4pmWhere: Stirling Management CentreHowLocally : contact your Local Unscheduled Care Team Nationally: [email protected]
http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/UnscheduledCare