parallel session 3.2 innovations in acute flow and capacity management
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3.2 Innovations in Acute Flow and Capacity Management
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Session Outline• Working definition
• How we have prioritised flow
• How we might want to think about flow in future
• What are the issues – why raise our ambition?
• Celebrating our existing work & what it tells us
• Next Steps
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Flow
1. a. To move or run smoothly with unbroken continuity, as in the manner characteristic of a fluid.1. b. To issue in a stream; pour forth: Sap flowed from the gash in the tree.2. To circulate, as the blood in the body.3. To move with a continual shifting of the component particles: wheat flowing into the bin; traffic flowing through the tunnel.
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Right treatment areaRight time Right teamRight care
(as efficiently as possible and within available resources)
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Flow = People
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How we traditionally consider flow
• Access targets and standards (point improvements)• Evolved from point improvements to pathway
management (unscheduled care / 18 weeks RTT/ cancer/mental health)
• Chunking up strategies and goals for the system (i.e. elective and unscheduled)
• Focus on improving constraints (delayed discharge)• Strategies having competing impacts (patient boarding)• Insufficient emphasis on individual patient experience?• Insufficient recognition of workforce design on flow and
of improvement and workforce relationship?
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How we should consider flow?
– Access/equity – safety issue– experience – efficiency
– 20/20 Vision demands on acute services are such that optimising throughput is critical
– Poor flow and inefficient use of capacity can drive up costs and may be compromising efficiency in all parts of the system
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Efficiency & Productivity Framework SR10Aim, Objectives & Scope
“To improve the overall quality and efficiency of NHSScotland while ensuring good value for money
and achieving financial targets.”
Key objectives:• Quality is not compromised,• NHSScotland will achieve financial
balance over the SR10 period,• NHS Boards are supported in
achieving efficiency targets and improving services, and
• Central co-ordination of support, monitoring, benefits realisation and challenge will be available to NHS Boards.
Acute Flow & Capacity work-stream formed to support NHS Boards to improve/optimise flow and to challenge unwarranted variation.
Productive Opportunity (based on
McKinsey DoH study and applied pro-rata up to £300m)
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The Problems of Patient Flow – Why raise our game?
Marilyn E Rudolph
• Peaks and valleys• Resource utilisation• Internal diversion – boarding• Increases in medical errors• Delays in patient care• Boarders and ED diversion (non IP areas)• Left without being seen• Decreased throughput = increased costs?• Increased length of stay• Staff and patient satisfaction
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Theory: The Quality Pyramid
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How Complex?
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Reform agenda domains Medicalclinicians
Medicalmanagers
Generalmanagers
Nursemanagers
Nurseclinicians
Recognise interconnectionsbetween the clinical andResource dimensions of care.
Ambivalent Accept Stronglyaccept
Accept Stronglyreject
Adopt a perspective thatbalances autonomy withtransparent accountability.
Reject Accept Strongly accept
Accept Ambivalent
Participate in processes that areoriented to bring clinical workwithin the ambit of workprocess control.
Strongly reject Stronglyreject
Accept Accept Accept
Accept the multidisciplinaryand hence team-based natureof clinical service provision.
Reject Ambivalent Accept Stronglyaccept
Accept
Born this Way? People and Reform
Peter Diegling
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National Results & Examples of Flow Improvement across NHS Boards
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50%
60%
70%
80%
90%
100%
Jan
-11
Feb
-11
Mar
-11
Ap
r-11
May
-11
Jun
-11
Jul-
11
Au
g-1
1
Sep
-11
Oct
-11
No
v-11
Dec
-11
Jan
-12
Feb
-12
Mar
-12
Month
Pat
ien
t jo
urn
eys
wit
hin
18
wee
ksElective Performance:
% of Patient Journeys within 18 Weeks
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0
20
40
60
80
100
120
Mar
-08
Jul-0
8
Nov-08
Mar
-09
Jul-0
9
Nov-09
Mar
-10
Jul-1
0
Nov-10
Mar
-11
Jul-1
1
Nov-11
Mar
-12
Quarter ending
Wai
t (d
ays)
Median (days) 90th percentile (days)
Median and 90th Percentile Waits for IP/DC
3525
105
63
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4 Hour Emergency Standard Compliance
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Emergency Care Pathways
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Elective/Unscheduled Admissions by Day of Week
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Variation within our Control?
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Smooth Elective Flows?
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NHS Board Examples
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NHS Tayside: Exploring Improvements for Effective Management of Capacity and Demand
• Demand activity calculated for each medical specialty• Reason code tracker completed by each Specialty to ascertain reasons why
capacity not achieved• Reason code tracker includes: Patients on EDISON / Patients due for
discharge who are placed out with speciality ward for non clinical reasons / Awaiting script / Awaiting tests/investigations (state what) / No bed in receiving hospital
• Improvement methodology applied to tailor improvements to each Specialty• Development of Capacity and Flow page on staff intranet which has daily
activity info, RAG status for each directorate/CHP, access to escalation plan and action cards
• Developing a 7 day acute physician delivered service model to ensure senior clinical decision making at the front door
• Interactive whiteboards with real time information
•
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A&E
Ad Unit
Sp Beds
CommunityBeds/IRT
NHBeds
Home
~60230/250
8.8(6) pts/d
Queue52 (62)
Waits4,8,12 hrs
QAssess.
~20
QAssess.49(49)
QAssess.
~18
Add. Capacity/ Boarding
31 (52)
Slow
15/6/2012
7.7(6.4) pts/d
~46/d
Improving Flow and Emergency Access Programme• Work streams = Front Door, Acute Admissions and
Specialty Flow, Community Flow
• Metrics and PDSA’s in each work stream
• Front Door examples –• Flow 1 and 2 / 4 hours • Fast track triage (time to 1st assessment)• Junior check in with Cons (referral rate /
clinical safety)• Specialty Review (time to specialty review)• Increased Consultant cover at peak times
(overall performance at 4 hours)
NHS Fife
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NHS Greater Glasgow & ClydeManagement of Inpatient Flow
Glasgow Royal Infirmary
– Creation of Emergency Receiving Complex – patients streamed directly to the following areas :
• Minor Injury Unit• ED Majors and Resus• Medical Assessment Unit – GP referred medical patients go
directly• Impact of the above has demonstrated a significant
reduction in breachers and in particular breach reason “wait for bed”
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NHS Greater Glasgow & Clyde
ED 4 Hour Breach Reasons by month: October 2010 - April 2012
0
100
200
300
400
500
600
700
800
Oct
-10
Nov
-10
Dec
-10
Jan-
11
Feb
-11
Mar
-11
Apr
-11
May
-11
Jun-
11
Jul-1
1
Aug
-11
Sep
-11
Oct
-11
Nov
-11
Dec
-11
Jan-
12
Feb
-12
Mar
-12
Apr
-12
Mo
nth
ly E
D 4
hr
Bre
ach
es
99 Not Known
98 Other reason
08 Major incident
07 Clinical reason(s)
06 Wait for 1st assessment
05B Wait for diagnostics test(s) - awaiting results
05A Wait for diagnostics test(s) - to be performed
05 Wait for diagnostics test(s)
04B Wait for initial A&E treatment - to be completed
04A Wait for initial A&E treatment - to commence
04 Wait for initial A&E treatment
03C Wait for a specialist - Wait for Mental Health/Psychiatrist
03B Wait for a specialist - Wait for Medical Specialty
03A Wait for a specialist - Wait for Orthopaedics
03 Wait for a specialist
02 Wait for transport
01 Wait for bed
NHS Board NHS GREATER GLASGOW & CLYDE Hospital GLASGOW ROYAL INFIRMARY
Month
Breach Reason
Source: ISD A&E2 datamart Management information Reports covering October 2010 - April 2012. Data is for management information purposes only and subject to change.
Note: When choosing board to view, do not choose '(All)' as will double count. Select NHS Scotland as board if wanting to view Scotland level data.
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NHS Greater Glasgow & ClydeManagement of Inpatient Flow
Use of Lean methodology
• Three teams configured to work at Western
Infirmary; Royal Alexandra Hospital; Victoria Infirmary to :
– Improve discharge process with increased number of beds available before midday
– Improve flow through ED/wards by addressing relationship issues between Medicine and DME
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NHS Lothian
• Implementation of Real Time Demand and Capacity Management (Resar, et al, 2011)
• Estimate of 10-15% in day capacity gains through implementing this methodology
• Project/Improvement Manager in place, estimate 6 months for implementation, further 6 for sustainability
• Focus on ‘Discharge Huddles’ and change in bed meeting process – accuracy of predictions – key issues to ‘unblock’
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What the World of Improvement Science says….
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Strategies for Managing Patient FlowS,G.Vaswani, M.C.Long, B.Prenney, E,Litvak
• Key principles:– System-wide not silos– Science-based, data-driven– Right structure before improving micro-processes– Compliance review and enforcement
• Operations Management– Critical path – minimise delays– Queuing theory – mismatch between demand and
resources– Simulation
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Natural Variability
• Random • Predictable• Can not be eliminated (or
even reduced) • Must be optimally
managed
Artificial Variability
• Non-random • Non-predictable (driven
by unknown individual priorities)
• Should not be managed, must be identified and eliminated
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A. N. Other Hospital
• Overcrowded
• Safety?
• Experience?
• Waits/Boarding
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The Natural Variation
Hospital
– Emergencies only– Queuing theory to decide size
and staffing– Run at 80% capacity
The Artificial Variation
Hospital
– Electives only– Smooth all admissions and
discharges– Run at 95% capacity
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Strategies for Managing Patient FlowS,G.Vaswani, M.C.Long, B.Prenney, E,Litvak
• Artificial Variability– Inadvertence e.g. LoS in HDU awaiting bed– Provider scheduling – ‘dysfunctional scheduling of
elective admissions’– Inappropriate management of flows
emergency/elective predictions, complexity • Effects
‘Artificial variability cannot be predicted or managed but must be investigated and eliminated’– Compromised quality of care– Decreased patient satisfaction– Decreased staff satisfaction– Operational inefficiency/ high cost of care
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Strategies for Managing Patient FlowS,G.Vaswani, M.C.Long, B.Prenney, E,Litvak
• Variability Methodology
Peaks in scheduled admissions is artificial variability
caused by dysfunctional scheduling of elective admissions– Identify variability– Classify as natural or artificial– Statistical test for randomness– Quantify – as deviation from ideal expected pattern– Eliminate/ significantly decrease– Manage natural variability by stratifying patients
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Strategies for Managing Patient FlowS,G.Vaswani, M.C.Long, B.Prenney, E,Litvak
• Variability Methodology IHO– Eliminating variability where you can– Optimally managing it where you can’t– Different types of variability in health care
• Clinical variability – illness and response to treatment• Flow variability – when• Professional variability – time taken
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Strategies for Managing Patient FlowS,G.Vaswani, M.C.Long, B.Prenney, E,Litvak
Phases • Separate flows• Smooth elective and queuing theory to emergencies• Once optimised estimate resource for system
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20/20 A Balanced Flow Hospital
• Flow = Quality
• Separate Flows
• Variation Smoothed
• Real Time Queuing Theory
• Whole System with Integrated Community Teams
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Intelligent Flow
• Making the flows/processes visible/separating them• Measurement & balancing measures• Patient experience & co-design• Complex adaptive thinking – the whole system• Counter-intuitive - most variation is in elective care and
is a supply not a demand problem• Generating the evidence base that poor flow is a patient
safety, efficiency and experience issue• Sustainable improvement will require a focus on quality,
workforce and governance
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Whole Hospital Acute Flow and Capacity Management
NHS Scotland’s Focus on Flow
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Key Improvement Messages
• Separate scheduled and unscheduled patient flows • Eliminate / minimise artificial variability wherever possible • Assign separate resources for scheduled and unscheduled
patients • Resources for unscheduled patients should be based on
clinically driven maximum acceptable waiting times – match capacity to the profile of demand
• Resources for scheduled patients should be based on maximising patient throughput and minimising unnecessary waiting
• Only after separation and matching capacity to demand examine fixed resources
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Next Steps - 2012
• Acute Flow & Capacity Management workstream progresses improvement projects and maintains close links to unscheduled care groups. Overarching improvement context
• Acute Flow & Capacity Management Programme Board receives proposals to test/implement a whole systems approach to flow and capacity planning – August 2012
• HSCMB, QAB and Efficiency Portfolio Board invited to agree proposals
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The Relationship between Flow, Quality and Cost
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Thanks to
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Question:
• If Patient Flow slows down:– do more patients die? – does cost go up?
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Agenda
• Programme Structure • High level measures
– What are we trying to improve?• Patient Flow
– Emergency and Elective• The constraints• The policies that need changing
• How to make changes happen
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Structure for an Improvement Programme
Board
Flow
Functional Departments
Support functions
Planned careEmergency
Clinical subspecialtiesMedicineSurgeryPaediatrics
HR SuppliesEstatesFinanceIT
Pathology PharmacyRadiology Theatres WardsClinics Therapies
Board
DH, SHA, Monitor, Health Commission etc.
A&E
Transport
GP GP
Ambulance
Intermediate careCommunity hospitalsLong term care
Seattle Children’s Hospital
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Board Report
Comments?
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Weekly A&E performance & crude death rateApril 2007 to Feb 2011
Non elective deaths / non elective discharges inc deaths by Date of ADMISSION
Weekly number of A&E breaches
Non elective death rate
Comments?
Dec 07 Dec 09 Dec 10Dec 08Foundation Status deferred
What happenedIn Sept 2009?
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Adult Non elective Rami(Rate Adjusted Mortality Index) (excl paeds, obs & midwifery)compared to average for peer group
Infection controlPalliative Care excluded > %15-64 years
admissions
Weekly Flow Cost Quality
Ap 07 to Ap – Jan 11A&E breaches &Non elective deaths / dischargesby date of admission
Total Pay costs(elective and non elective)Agenda for change
RecruitOpen new wards
Foundation Status deferred
Whathappened inSeptember 2009?
Comments?
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What have we learned?
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What the Warwick and Sheffield teams learned
• Plot the dots!– weekly data – reviewed monthly: Board
• Monthly 2 hour meeting:– Executives, senior clinicians and Dpt. heads from
across the health & social care system • Study, Adjust, Plan, Do
– When did the statistically significant changes happen?– Why?
» What did WE change?
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Understanding Flow
Board
Flow
Functional Departments
Support functions
Planned careEmergency
Clinical subspecialtiesMedicineSurgeryPaediatrics
HR SuppliesEstatesFinanceIT
Pathology PharmacyRadiology Theatres WardsClinics Therapies
Board
DH, SHA, Monitor, Health Commission etc.
A&E
Transport
GP GP
Ambulance
Intermediate careCommunity hospitalsLong term care
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High Level Emergency System Map
Accidentand
Emergency
Community Hospitals
AssessmentUnit(s)
Permanent place of residence
IntermediateCare
(services delivered in the patient’s home)
Death
Hospital
SpecialistWard
GP
Ambulance
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Emergency Demand
Comment?
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Emergency Admissions
Comment?
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Relationship between flow in, A&E performance and deaths and emergency admissions
Comments?
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Adult Non elective Rami(Rate Adjusted Mortality Index) (excl paeds, obs & midwifery)compared to average for peer group
A&E breaches &Non elective deaths / dischargesby date of admission
Weekly Flow Cost Quality
Ap 07 to Ap – Jan 11
Infection controlPalliative Care excluded > %15-64 years
admissions
Foundation Status deferred
Closure of Community HospitalSept 2009
Agenda for change
RecruitOpen new wards Total Pay costs
(elective and non elective)
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High Level System Map
Accidentand
Emergency
Community Hospitals
AssessmentUnit(s)
Permanent place of residence
IntermediateCare
(services delivered in the patient’s home)
Death
Hospital
SpecialistWard
GP
Ambulance
Closed 40 beds
Sept 2009
Continuing Health Care funding process changed
Oct 2009
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Lesson for Boards:
Poor A&E performance is due to poor flow OUT– Constraints are under our control
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Lesson for Performance Management
• Plot the dots!– Trend lines should be removed from Excel
– Statistical Process Control• Reveals the voice of the process
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What did we learn?
• Plot the weekly emergency admissions by age group:• 0 to 15• 16 to 64• 65 to 79• 80 and plus
• Plot Patients-in-Progress (work-in-progress):– very sensitive to changes in demand x LOS:
• A&E performance (breaches)• Midnight bed occupancy
– See later
Correlates with the high level patient flows
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Emergency admissions 80 years +
Confirms that poor flow is NOT due to increased admissions of patients > 80 years
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High Level Emergency System Map
Accidentand
Emergency
Community Hospitals
AssessmentUnit(s)
Permanent place of residence
IntermediateCare
(services delivered in the patient’s home)
Death
Hospital
SpecialistWard
GP
Ambulance
(0 to15) 16 to 64 65 to 79 80 and plus years
Warwick
Sheffield: GSM
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GSM: How Many Bed Nights Do They Stay?
Pareto of Bed Nights for Home to Home Patients
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 6
12
18
24
30
36
42
48
54
60
66
72
78
84
90
96
10
2
10
8
11
4
12
0
12
6
13
2
13
8
14
4
15
0
15
6
16
4
17
5
18
9
20
5
26
3
Bed Nights
Cu
m F
req
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Day to day Admissions Discharge mismatch
NEL Admission Discharge mismatch
01020304050607080
date
nu
mb
er
of
NE
L p
ati
en
ts
ad
mtt
ed
an
d d
ich
arg
ed
Total NEL admissions (NEL+ NEL other)
Total NEL discharges (NEL+ NEL other)
Elective Admission Discharge mismatch
01020304050607080
01/1
2/20
07
08/1
2/20
07
15/1
2/20
07
22/1
2/20
07
29/1
2/20
07
05/0
1/20
08
12/0
1/20
08
19/0
1/20
08
26/0
1/20
08
date
Nu
bm
er o
f el
ecti
ve p
atie
nts
ad
mit
ted
an
d d
isch
arg
ed
EL admissions
EL discharges
1. Reduce dailyvariation in discharges
2. Smooth Variation inPLANNEDElectiveAdmissions
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0
50
100
150
200
250
300
350
400
450
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Time of Arrival into A&E Time of Departure out of A&E to Main Hospital
In-day mismatch between Emergency admissions and Specialist capacity
X junior staff
+Y
specialist consultants?
Patients admitted when capacity is not available
Assessment units are storage units to hold the patients until the specialist capacity is available the following day
Minimal capacity
Minimal capacity
12.0000.00 23.5906.00 18.00
When is the Specialist Capacity available?
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Assessment Process at April 2009
History & examination& initial treatment
TriageRequestsTest & imaging
Perform tests& imaging
Senior ReviewPlan definitive treatment
History & examination
Transfer to Assessment Unit
4 hours.
NursingObs’
Senior review
ArriveAt A&E
NursingObs
Up to 12 hours overnightUp to 24 hours post arrival at hospital
A&E Assessment Unit
Perform tests& imaging
?
= value
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What do we need to do instead?
0
50
100
150
200
250
300
350
400
450
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Time of Arrival into A&E Time of Departure out of A&E to Main Hospital
0
50
100
150
200
250
300
350
400
450
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Time of Arrival into A&E Time of Departure out of A&E to Main HospitalTime of Arrival into A&E Time of Departure out of A&E to Main Hospital
Specialists availableSeeing patients on wards
Discharging patientsAdmitting patients
Minimal capacity
12.0000.00 23.5906.00 18.00
The specialty capacity needs to be available:
08:00 21:00
Pull patients forward into the working day:• Stop making them wait 3:59 minutes…..• Stop duplication
Right decisionsOn time Every timeIn full
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‘Future’ Assessment Process(Now current as at April 2012)
History & examination& initial treatment
Plan for diagnosis
RequestsTest & imaging
Perform tests& imaging
Senior specialist ReviewPlan definitive treatment
NursingObs’
ArriveAt A&E
2 hours
Transfer to Appropriate specialist areaincluding homewith PT/OT /SShome assessment at home
1 hour
Safe ambulatory care process now possible
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Demand: numbers by day
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All admissions from A&E by hour Mondays May to Oct 08
0
1
2
3
4
5
6
7
8
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Hour of arrival
Ad
mis
sio
n
Max
Min
Avg
Av + 1 SD
Av +2 SD
What is the rate of production required?
Reduce dailyvariation in discharges
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Medical Emergencies Arrival Time08:0008:1508:3008:4509:0009:1509:3009:4510:0010:1510:3010:4511:0011:1511:3011:4512:0012:1512:3012:45
All Emergencies Arrival Time08:0008:1008:2008:3008:4008:5009:0009:1009:2009:3009:4009:5010:0010:1010:2010:3010:4010:5011:0011:1011:2011:3011:40
Junior Doc Nurse X-ray Consultant doc
Planning Capacity of the workforce
4admissions/hr.
6admissions/hr.
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Improving Flow (front end)
• Pooled junior docs– A&E, MAU and specialty on call– Staggered start times on A&E/MAU
= Increased availability from 08:00 to 10:00
• MAU consultants continuous flow• Speciality take every day: admissions• Heartbeat system for tracking patients
• Wards– Consultant ward round every day: discharges
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Functional departments
Board
Flow
Functional Departments
Support functions
Planned careEmergency
Clinical subspecialtiesMedicineSurgeryPaediatrics
HR SuppliesEstatesFinanceIT
Pathology PharmacyRadiology Theatres WardsClinics Therapies
Board
DH, SHA, Monitor, Health Commission etc.
A&E
Transport
GP GP
Ambulance
Intermediate careCommunity hospitalsLong term care
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Do this hour’s work this hour:
• Emergency Blood turnaround:– Bottleneck for emergency samples = centrifuges
Change: • Now a centrifuge starts every 3 minutes whether full or not
• IP blood monitoring on wards– Bottleneck: Phlebotomists & transport to lab
Change:• Porters running between phleb’s and lab• Steady flow of samples into lab• all results back by 10:30 a.m. for ward rounds
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1 year later
• Warwick
• Focus on:– A&E, – Assessment units and wards– Diagnostics– Ward rounds– TTOs
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Comments?
Infection control Palliative Care excluded
Agenda for change RecruitOpen new wards
Foundation Status deferred
Close CommunityHsp Sept 09
Acquire Community services
Dec 2010: flow improvements start
Reduction in death rate
Increased %16 to 64 years
Flow doesn’trecover from Sept 2009bed + staffclosures
Nobody addressedthe CHC admin delays causing the long LOS
Organisationchange disrupted the Admin flow even more
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1 Year later
• Sheffield
Geriatric and stroke medicine– Focus on reducing the admin constraints (policies)– Check List and CHC assessment process
• 42 page document• 18 man hours of work• Min time (LOS) = 30 days+
– Home assessment at home on day of discharge• Referral to Social Services by physio to social services• SS package in place within 48 hours (Upper process limit)
– Home of choice:• out to residential home, CHC afterwards
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Home of choice
Daily
Weekly
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Lessons for executive support services
Board
Flow
Functional Departments
Support functions
Planned careEmergency
Clinical subspecialtiesMedicineSurgeryPaediatrics
HR SuppliesEstatesFinanceIT
Pathology PharmacyRadiology Theatres WardsClinics Therapies
Board
DH, SHA, Monitor, Health Commission etc..
A&E
Transport
GP GP
Ambulance
Intermediate careCommunity hospitalsLong term care
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Lessons for executive support services
• HR: – Systems thinking and improvement science for A4C 8 & above– Match staff capacity to patient demand: 7/7, 365– Heads of functions = responsibility for end-to-end process
Focus is on Flow,
WIP incurred accountable to the Dpt. concerned.
• IT – Information in real time– Time series data
• Estates:– Reduce transport and motion– Co-location of process resources
• Supplies – Just-in-time
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Finance
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Pareto analysis of the pay costs in one Trust for one month by employee.
50% of cost
20% of staff
Role of senior managers is toimprove process flow through the most expensive value adding staff =clinicians
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Dpt 1 Dpt 2 Dpt 3 Dpt 4 Dpt 5 Dpt 6
Change the Finance Paradigm
Economies of Scale Economies of Flow
£5/hr
£1/hr
£2/hr
£1/hr
£1/hr £2
/hr
Dpt 1 Dpt 2 Dpt 3 Dpt 4 Dpt 5 Dpt 6
Activity x PbRincome
DemandPatients /hr
CapacityPatients/hr
Nu,ber of Patients treated successfullyLand lives ‘saved’
Drives Dpt manager to do more activity at less costAcquires ‘new business’ But what happens to flow?
Department Cost Activity
= unit cost= waste
So focus is on improving value delivered and incomeThis depends on moving resources to support the constraint
constraint
The constraint should be the most expensive resourcein the process = in Dpt 2. How can we optimise productivity through the most expensive resource?
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Finance
• John Darlington’s paper• http://www.leanuk.org/downloads/LS_2010/paper_lean_bu
siness_case.pdf
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How to make changes happen
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HistoryExamination Assessment30 minutes
Nil by mouth 4 hours
Fullblood Count5 minutes
Endoscopy&Breath test30 minutes
Transfuse8 hours
Discussion with cardiac centreRe stent15 minutes
Cross match40 mins
Discharge With PlanAnd Rx15 minutes
82% of time and resource wasted
Poor quality experience and outcomeFrom a Poor Quality System
Value adding
Non Value adding
34 hours
8 days x 24 hours18% of time value adding=
CheckFBC 5 minutes
Rest & dehydrate for 20 hours
Get Everyone on Board
Patient’s experience of waste
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The Doctors can lead the change…..
• Very complex system:– Like a human body!
• Understand– Anatomy – Physiology (flows)– Plot the dots: BP, temp, pulse, resp’s ….– Diagnosis– Treatment (releave the constraints)– Look for changes in the pattern of variation (SPC)
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Get the Managers on Board
• Top Down Command and Control is impossible: – Not possible for one person to understand whole end-
to-end process or System.
• Facilitate Big Room Meetings– Get the everyone in a room – Listening to each other– Conversations based on facts: – Study, Adjust, Plan, Do, – Monthly and Weekly reviews
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Big Room Process
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Summary
• Quality is a System property• Track patient flow (WIP), death rate and cost over time.
– Increasing cost doesn’t always improve flow– Reducing cost can have grave consequences
• Improve processes to reduce delays and inventory (WIP)– Match staff capacity to patient demand– Do this hour’s work this hour
• Shift from:– Unit Costing: Dpt cost/activity– to Flow Accounting: throughput at constraint/total process cost– The constraints are policies or availability of staff, not beds.
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What have we learned ?
• Nuggets
• Niggles
• Nice-if
• NoNos
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